Report on the Diagnostic Study of DSF-MHV Scheme of Bangladesh by Tareq Salahuddin

December 2016 Dhaka, Bangladesh

Report on the Diagnostic Study of Demand Side Financing – Maternal Health Voucher Scheme of Bangladesh (DSF – MHVS)

M. Mahmud Khan, PhD Professor, Department of Health Services Policy and Management, University of South Carolina, Columbia, SC, USA. & Dr. Md. Abdur Rahman Khan Former Director General, Directorate General of Health Services, MOHFW, Government of Bangladesh.

December 2016

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Executive Summary The purpose of this report is to present the results of a diagnostic study of Demand-side financing of Maternal Health Voucher Scheme (DSF-MHVS). The study has examined how the programme is being currently implemented and what specific policy changes and reforms may help improve Value for Money (VfM) in DSF-MHVS. The focus has been to better understand the problems and concerns of DSF-MHVS from the perspectives of managers, policy makers, implementers, health care providers and the beneficiaries. This study followed a â&#x20AC;&#x153;mixed methodâ&#x20AC;? approach by combining results of literature review, quantitative data analyses and qualitative research methods. Data collected by the programme were obtained for the quantitative analyses and additional information was collected through a survey of WHO Quality Managers (QMs) in charge of implementing the programme in all 53 DSF upazilas of the country. The qualitative aspect of the research is based on discussions and interviews with policy planners, decision-makers, development partners, programme managers, programme implementers, health care providers and the beneficiaries. The principal objectives of DSF-MHVS are to increase demand and utilization of maternal health services, to improve access to and utilization of safe delivery, to encourage institutional delivery and to improve equity in the utilization of maternal health services. In 2015-16, the scheme enrolled more than 107 thousand beneficiaries in 53 upazilas. The DSF-MHVS provides poor mothers with vouchers that can be used to obtain three antenatal care (ANC), safe delivery, postnatal care and assisted delivery or caesarean section delivery, if needed. The scheme provides transportation costs (up to five trips) and cash incentives for safe deliveries (either in a facility or at home) to mothers for first and eligible second deliveries (mothers adopting family planning after first delivery). Literature review indicates that the programme has been successful in increasing utilization of maternal health services by pregnant women participating in DSF-MHVS compared to the utilization by non-participants. The financial resources of the programme flow through the Ministry of Health and Family Welfare (MOHFW). The fund is released to a MHVS account operated by Line Director (LD) of Maternal, Neonatal, Child and Adolescent Health (MNCAH), MOHFW. From this account funds are transferred in instalments to MHVS upazila account and then to seed fund account for paying private and public sector providers for services delivered to MHVS beneficiaries. Literature review identified a number of issues and concerns related to the implementation and functioning of DSF-MHVS: administrative and management concerns (e.g., some of the MHVS implementers at the upazila and union levels were not aware of policies and procedures of the programme), financial issues (e.g., Significant delays in the payment of incentives to beneficiaries), target group identification issues (e.g., eligibility criteria for enrolment in the programme not followed properly), quality and comprehensiveness of health care services delivered (e.g., half of MHVS health facilities were not Comprehensive Emergency Obstetric Care (CEmOC) facilities), lack of knowledge of beneficiaries on MHVS, outof-pocket (OOP) expenses (e.g., beneficiaries paid for some of the covered services) and provider payment and its impact on provider behaviour (e.g., over-utilization of caesarean section delivery). Discussions with policy makers, representatives of development partners and field level implementers identified similar concerns and issues. Most were of opinion that DSF-MHVS has improved access to maternal health services and the programme should be strengthened and scaled-up. Delay in flow of funds creates significant obstacles in running DSFMHVS and some suggested creating advance payment account or imprest fund for timely payment of cash incentives, travel allowances, etc. to beneficiaries. It was suggested that the programme should allow a number of options for i

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) disbursing money to beneficiaries including online banking, e-cash transfer, use of postal money order, etc. The discussions also mentioned the need for reorganization of DSF committees, involvement of independent third party for monitoring quantity and quality of services delivered and disbursement of funds, change in the criteria for identifying the poor, etc. Field visits identified a number of additional issues. During January-August 2016, in Daudkandi upazila, the number of ANC services used at Upazila Health Complex (UHC) by DSF-MHVS participants was 458 compared to 3115 for nonparticipants. 13% of all ANC services at the UHC were offered to voucher holders and they accounted for 19.5% of all normal deliveries. About 71% of all C-section deliveries at the UHC were conducted on voucher holders. Among the mothers delivering in UHC, C-section rate was 40.8% for voucher holders and 6.3% among non-DSF participants, indicating possible overutilization of C-section delivery under DSF. Discussions with the owner of a private hospital in Daudkandi upazila indicate that the market prices for different maternal health services were significantly higher than the unit prices set by the DSF-MHVS. Although the private facility manager/owner mentioned that they accept DSF-MHVS reimbursement as full payment for services, some beneficiaries reported paying extra for services they have received. Some DSF-MHVS mothers also mentioned buying drugs and supplies at both private and public health care facilities. Some beneficiaries of DSF-MHVS expressed concerns about high level of C-section delivery. The field trips found that the DSF committees were not active in the two areas visited. Some pregnant women were recruited into the programme very late in their pregnancies implying weak programme implementation practices as well as lack of community awareness about the programme. Important concerns identified by the QMs were: problems with system of distributing money through bank accounts; non-availability of clinical personnel in health facilities; delayed payments to beneficiaries; lack of communication among village, union and UHC program personnel; lack of interest of Upazila Health and Family Planning Officers in the programme and lack of accountability within the programme. The QMs also suggested some reforms to address the concerns. Most frequently mentioned suggestions were: ensure regular flow of funds for timely reimbursement to beneficiaries, consider disbursing money through Bikash, postal or other e-cash system, DSF should ensure availability of right mix of health care providers, monitoring and supervision of the programme should be strengthened, improve understanding of mothers about the program, criteria for defining poverty should be revised. Given the utilization of maternal health services in the programme areas, total budget needs become Tk.126.4 million for paying for the services provided by health care personnel. The most important item within provider payment was the cost of caesarean section delivery, which represents about 57% of total health service expenses. The budget needs for 201516 to pay the beneficiaries was about Tk. 146.7 million. Institutional delivery related incentives represent about 63% of total payments. The administrative cost at the facility level, which includes incentive payments for UHFPO and RMO at the UHC and salary payment for one office staff per UHC, is estimated at Tk. 5.6 million. Therefore, total service-related expenses in 2015-16 should be Tk. 278.7 million. According to the budget and expenditure reports, average annual budget of the programme over the last five years was about Tk. 12.674 million per upazila or Tk. 671.72 million per year for the programme in 53 upazilas. The expense on the average is relatively high due to higher enrolment in the programme prior to 2014-15. Excluding the expenses related to payment for services and incentive payments for beneficiaries, the remaining expenses were Tk.13.21 lac or Tk.1.321 million per upazila. A number of MOHFW personnel are involved with the programme and additional personnel are ii

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) appointed by the World Health Organization (WHO). Since the programme requires the presence of these administrative and operational personnel, the value of their time should be included in the programme cost. Unit costs associated with the programme are reported below including the personnel cost not in programme budget. Provider payments for the services delivered:

Tk. 1,181 per voucher distributed

Paying beneficiaries for travel and incentives:

Tk. 1,371 per voucher distributed

Paying UHFPO and RMO for delivery cases:

Tk. 100 per institutional delivery

Office staff wage payment (upazila level):

Tk. 18,720 per upazila per year

Expenses on meetings, printing, supplies, copying:

Tk. 1.321 million/upazila

Expenses related to advertisement/publicity:

Tk. 0.10 million/upazila

Additional personnel cost, management/implementation:

Tk. 0.45 million/upazila

Only 15 upazilas in the programme belong to the poorest 20% of upazilas of Bangladesh while another 11 belonged to second poorest quintile. The selection of upazilas was not based on geographic poverty rates. If the upper poverty line of 2010 is used for identifying the poor pregnant women in 53 upazilas under DSF, the programme should have distributed 91,558 vouchers (assuming that poverty rate among first and second order pregnancy cases is 10% higher than upazila poverty rate) in 2015-16 but the programme actually distributed 107,000 vouchers, 17% higher than the number of poor women in the upazilas. Some suggestions are listed below by specific areas of concern.

Flow of fund related issues: 1. It is important to identify the causes of delay in the flow of funds. The time lag between the adoption of budget and release of funds to MOHFW needs to be reduced to less than 30 days. Time needed for flow of funds from MOHFW to upazila level should be reduced as well. 2. Ministry of Finance may consider creating an imprest account to be administered by the management of DSF-MHVS. The management entity can potentially be a financial entity or a third party administrator. 3. The programme should allow beneficiaries to choose from a number of alternative ways of receiving payments. The mechanisms for paying may range from bank accounts including online banking and micro-credit accounts, postal money orders or e-cash or mobile transfer of funds. 4. The requirements for opening bank accounts should be simplified.

Programme management related issues: 5. The committees formed for planning and administering different aspects of DSF-MHVS should be carefully reviewed. The number of committees may be reduced. 6. The presence QMs appears critical for proper implementation and management of programme activities at village, union and upazila levels. Programme should appoint administrative personnel at upazila level who will be in charge of local level programme activities including data management, verification of eligibility, keeping contacts with village and union level stakeholders and beneficiaries. 7. The programme needs an independent monitoring entity to verify quantities of services delivered as well as the quality. The monitoring system should also collect information on out-of-pocket expenses of beneficiaries. iii

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS) 8. Programme should adopt a systematic social mobilization strategy to improve programme related knowledge of all stakeholders including programme managers and implementers, DSF-MHVS beneficiaries and health care providers. It is also important to develop a “user-friendly” booklet to make mothers aware of pregnancy related health issue, safe delivery practices, care of newborn and importance of breastfeeding.

Incentive payment related issues: 9. The price schedule used by the programme should be carefully evaluated to ensure that the prices are consistent with the social objective of improving maternal and neonatal health and improving access to health care services by poor pregnant women in rural Bangladesh. 10. Incentive payments to public sector health care providers for services delivered to DSF-MHVS beneficiaries represent a conflict of interest situation. Solution to this problem should be identified.

Targeting the beneficiaries: 11. Indicators for selection of poor households should be revised. Income-based poverty indicators are difficult to verify and the programme should devise easy to monitor poverty indicators for identifying the target population. 12. Since the maternal mortality ratio was found to be highest for the middle wealth quintile in Bangladesh (by Maternal Mortality survey), changing the eligibility criteria to allow inclusion of poorest 50% may be considered if targeting the programme towards the poor is desired. Costs and benefits of universal coverage should also be evaluated. 13. Targeting efficiency of DSF-MHVS is not known. The programme should carry out a community level survey to estimate how efficient the programme is in reaching the poor. 14. For inclusion of new upazilas, the programme should consider “geographic targeting”, i.e., selecting the poorest upazilas of the country for expansion of DSF-MHVS.

Specific Suggestions 

Expand the programme by using geographic targeting, i.e., targeting high poverty rate upazilas. In high poverty rate areas, universal coverage can be adopted.



Delay in flow of funds should be addressed immediately. Imprest account may be created for ensuring timely payment to beneficiaries as well as to health care providers.



The programme should allow beneficiaries a number of options for receiving incentive payments, such as, direct deposit into bank accounts, e-cash, mobile banking, postal money order, etc.



Price schedule used by DSF-MHVS should be carefully reviewed to understand and correct how the unit prices affect patient and provider behaviour.



Purchaser and provider of health care services should not be the same entity and at the upazila level, roles played by UHC should be redefined.



The benefit package needs updating. The benefit package should include all services required for safe delivery including ultrasound for complicated pregnancies, tests for blood sugar and blood grouping. User payments for covered services should be prohibited.



Informational booklet on pregnancy, progression of pregnancy, food and nutritional needs, danger signs of pregnancy, pregnancy complications, safe delivery practices, care of newborn, etc. should be developed and distributed to all pregnant women in the area.

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS) 

Diagnostic studies of similar programmes should be carried out to identify potential economies of scope, i.e., whether the value-for-money in each of the programmes can be improved by integrating it with other similar programmes. The benefits and costs of integrating DSF-MHVS with similar social protection programmes should be examined.



The programme should develop a comprehensive integrated Management Information System (HMIS) for DSFMHVS, which can be integrated with UHC HMIS.



Household survey in DSF-MHVS area should be carried out to understand targeting efficiency. The survey should also obtain information on possible over-reporting of service utilization. Facility-based survey should also be organized to measure quality and quantity of maternal health services produced in public and private health care facilities.



This report was discussed in a meeting in the MOHFW. Major stakeholders of the scheme participated in the meeting. There was a general consensus in the meeting on the findings and suggestions made in this report. Realistic reform plan should be prepared for implementation of the recommendations put forward in the report. The GOB and SPFMSP project should take necessary initiatives in this direction.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Contents Executive Summary ................................................................................................................................................................................................ i Abbreviations ................................................................................................................................................................................................... vii I.

Background to DSF-MHVS................................................................................................................................................................... 1

II.

Objectives of the diagnostic study ................................................................................................................................................... 2

III.

Methodology of the study ................................................................................................................................................................... 2

IV.

The Demand Side Financing Programme: Maternal Health Voucher Scheme ............................................................. 3 a.

DSF-MHVS Objectives and its Development ............................................................................................................................ 3

Identifying the poor: the official criteria and distribution of vouchers............................................................................. 3

Management of the voucher scheme......................................................................................................................................... 4

Flow of funds and fund transfer mechanism ........................................................................................................................... 4

Benefit Package and Payment Rates for Voucher Holders and Health Care Providers .............................................. 6

Results of the Diagnostic Study ......................................................................................................................................................... 7 a.

Issues and Concerns identified by other studies .................................................................................................................... 7

Opinion of policy-makers and key informants ........................................................................................................................ 9

Field visits: Opinions from the field ........................................................................................................................................... 10

Survey of WHO Quality Managers (QMs) .................................................................................................................................. 11

Analysis of Programme Data ....................................................................................................................................................... 12

Targeting Efficiency of MHVS ...................................................................................................................................................... 18

VI.

Policy Suggestions ......................................................................................................................................................................... 20 a.

Issues related to flow of funds .................................................................................................................................................... 20

Administration and management related issues ................................................................................................................. 22

Paying the providers ...................................................................................................................................................................... 22

Targeting poor mothers ............................................................................................................................................................... 24

Knowledge and communication related issues in the programme ............................................................................... 25

Data needs for improving effectiveness and efficiency of DSF ......................................................................................... 25

Comparison with other similar social protection programmes ....................................................................................... 26

VII. Concluding Remarks ............................................................................................................................................................................... 27 References .............................................................................................................................................................................................................. 30 Annex A: DSF Upazilas with their 2010 Poverty Head-Count Ratio ....................................................................................................... 31 Annex B: Questionnaire used to survey the Quality Managers of DSF ................................................................................................. 35 Annex C: Budget and Expenditures of DSF MHVS ...................................................................................................................................... 37 Annex D: List of Poorest 50 upazilas of Bangladesh .................................................................................................................................. 41 Annex E: List of Individuals met during the field visits and in Dhaka, Bangladesh .......................................................................... 43 Annex F: Comparative Summary Statements for DSF-MHVS ................................................................................................................. 45 Annex G: Minutes of the meeting on report presentation and discussion ......................................................................................... 50

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Abbreviations ANC

Ante Natal Care

CEmOC

Comprehensive Emergency Obstetric Care

CSBA

Community based Skilled Birth Attendants

DHS

Demographic Health Survey

DSF

Demand Side Financing

EmOC

Emergency Obstetric Care

GOB

Government of Bangladesh

FWA

Family Welfare Assistant

FWV

Family Welfare Visitor

Health Assistant

HMIS

Health Management Information System

IMR

Infant Mortality Rate

MHVS

Maternal Health Voucher Scheme

MMR

Maternal Mortality Ratio

MNCAH

Maternal, Neonatal, Child and Adolescent Health

MOF

Ministry of Finance

MOHFW

Ministry of Health and Family Welfare

OOP

Out Of Pocket

PNC

Post Natal Care

Quality Manager

SPFMSP

Strengthening Public Financial Management for Social Protection

UHC

Upazila Health Complex

UHFPO

Upazila Health and Family Planning Officer

UNO

Upazila Nirbahi Officer (Upazila officer in charge)

VfM

Value for Money

WHO

World Health Organization

vii

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) This report is a diagnostic study of one specific social protection program, the Demand Side Financing of maternal and neonatal health, the Maternal Health Voucher Scheme (DSF-MHVS). The diagnostic study has examined the process of programme implementation in practice and identified some specific policy changes and reforms that may help improve value for money (VfM) in DSF-MHVS. The study was carried out during September - December 2016. The focus of the study has been to better understand the problems and concerns of DSF-MHVS from the perspectives of managers, policy makers, implementers, health care providers and the beneficiaries.

Background to DSF-MHVS

Maternal, Neonatal and child health care are priority health care services for Bangladesh and the five year plans of the country have consistently emphasized the importance of improving maternal and child health. Although Bangladesh has seen significant improvements in health outcomes, further progress in maternal and child health can be achieved through improved access to quality health care services to all, especially to the disadvantaged population groups. Maternal Mortality Ratio (MMR) of Bangladesh declined from 3.29 per 1000 live births in 2000 to 2.15 in 2011 (BBS, September 2016). It further reduced to about 1.43 per 1000 live births by 2014. Under-five mortality also declined rapidly from 94 per 1000 live births in 2000 to 46 in 2014. Improvements in health status happened in all socioeconomic groups but disparity in health outcomes has remained relatively high. For example, MMR among the lowest wealth quintile population was about 90% higher than the highest quintile (NIPORT, December 2012) but interestingly maternal mortality survey found that the MMR was not the highest among the poorest group. The MMR was reported to be the highest among the middle wealth quintile, implying that further improvements in MMR will require more broad-based intervention rather than targeting the poorest. According to the Demographic and Health Survey (DHS) of Bangladesh, 64% of women who gave birth in three years preceding the survey received antenatal care (ANC) from trained personnel and 31% had four or more ANC visits. 95% of highest wealth quintile mothers received ANC from trained personnel while it was only 36% for the lowest quintile. Percent of women receiving ANC from public sector was 41% among the lowest wealth quintile and 24% for the highest quintile while the percentages receiving ANC from private providers were 33% and 71% for lowest and highest wealth quintile respectively. Therefore, public sector health care facilities are the predominant source of maternal health care services for poor households in Bangladesh. About 62% of all births in Bangladesh took place at home in 2014, 13% in public sector health care facilities and 22% in private facilities. Percent of all births happening in health care facilities was only 14.5% among the lowest wealth quintile and 70% among highest quintile. Deliveries done through caesarean sections increased rapidly over the years, from 4% in 2004 to 23% in 2014. Rapid increase in the caesarean section rates is a concern even though it was very low in 2004. More than 60% of women did not receive any postnatal care in the preceding three years prior to the DHS survey in 2014. Those who received postnatal care (PNC), only 31.5% received the care from trained medical personnel. PNC utilization gap between lowest to highest wealth quintile was quite large as well. Among the lowest wealth quintile, PNC utilization rate was 13% and for the highest quintile it was 63% (NIPORT, Bangladesh Demographic and Health Survey 2014, March 2016). Therefore, utilization of ANC, safe delivery and PNC can be improved significantly in Bangladesh, especially for the poorer sections of the population. In Bangladesh, out-of-pocket (OOP) payment for obtaining formal or informal health care services represents a large part of total health care expenditure. In 2012, OOP payments by households accounted for 63% of total health expenditure (HEU, 2012). One study reported that about 64% of pregnancies sought at least some maternal health services from public or private facilities and almost all incurred OOP expenses. The average OOP expense (using weighted average of public 1

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) and private facility users) was about $108 per institutional delivery. Even for users of public sector health facilities, OOP was found to be about $46 (Rahman, Rob, Noor, & Bellows, 2013). Another study reported that for normal deliveries average OOP was about $29 and deliveries with complications incurred an average OOP expense of $261 (Hoque, PowellJackson, Dasgupta, Chowdury, & Koblinsky, 2012). High burden of OOP expenses is likely to affect adversely utilization of maternal and child health services. Policies to lower OOP should improve utilization of maternal health services. The DSF- MHVS was designed to increase the utilization of maternal health services in Bangladesh in order to improve maternal and neonatal health outcomes. The scheme encouraged utilization of quality maternal health services delivered by trained clinical personnel.

II.

Objectives of the diagnostic study

This diagnostic study intended to identify and document major concerns and issues with the MHVS. Potential sources of inefficiencies of the scheme were also explored. More specifically, the objectives of the study are: 1.

To review and understand different characteristic features of the scheme including its objectives, program design, eligibility criteria, etc.

To review different types of processes adopted for implementation of the scheme including targeting of beneficiaries; timely and quality services being offered to the beneficiaries and issues and challenges currently being faced by the service providers as well as beneficiaries.

To provide recommendations to improve value for money for the programme.

To analyse possible benefits and costs of expanding the scheme from its current level of operations and to discuss possible economies of scale.

To provide information on administrative and other costs of the programme to enable future estimation of potential cost savings through economies of scope, i.e., combining DSF-MHVS with other similar programs.

To derive cost parameters for use in future studies to estimate budget impacts of reformed plans and/or to develop integrated approach of providing social safety net services and interventions at national and sub-national levels.

III.

Methodology of the study

To achieve the objectives of the study, a number of methodological approaches were adopted. The method adopted may be termed as a mixed-method approach where multiple research strategies are followed. Both qualitative and quantitative research methods were used to help diagnose the programme concerns without conducting a full evaluation of the programme. One of the main objectives of the study is to identify specific approaches for improving value for money (VfM) and the focus has been to collect information on potential sources of inefficiencies through key informant interviews, qualitative surveys and analysis of administrative data. Specific methodological steps are listed below. a.

Literature review: issues and concerns identified by previous studies on DSF-MHVS. Are the evidences consistent enough to come up with actionable changes or reforms? Both published and unpublished studies were reviewed.

Key informant interviews: discussions with policy makers at national and sub-national levels as well as personnel involved in the implementation of the program at the field level.

Field visits: two field visits were organized. The field visits included one high-performing DSF-MHVS area and one relatively low performance area.

Discussions with World Health Organization (WHO) DSF-MHVS Quality Managers (QMs): to identify problems, issues and concerns from the point of view of implementers at the field level (QMs are involved with various operational aspects of the programme).

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) e.

Survey of WHO QMs: a structured questionnaire was used to collect information from all QMs appointed to manage DSF-MHVS at the upazila level.

IV.

Quantitative analysis of programme data: DSF-MHVS related data were obtained for the years 2011 to 2016.

The Demand Side Financing Programme: Maternal Health Voucher Scheme a. DSF-MHVS Objectives and its Development

The DSF-MHVS is a demand side financing strategy to achieve a number of objectives related to improvements in maternal and neonatal health in Bangladesh. The specific objectives of the programme are: (i) to increase demand and utilization of maternal health services, (ii) to improve access and utilization of safe delivery, (iii) to encourage institutional delivery and (iv) to improve equity in the utilization of maternal health services. During the year 2015-16, the scheme enrolled more than 107 thousand beneficiaries which represented about 3% of all pregnancies of Bangladesh (assuming crude birth rate of 20 per 1000 population and July 1 2016 population as 165.5 million). Therefore, the programme currently covers only a small proportion of all births happening in the country. According to the official procedures of the programme, the DSF-MHVS intends to provide poor mothers with a booklet containing a number of vouchers which the pregnant women can use to obtain three ANCs, safe delivery and PNC free of charge. The vouchers also cover assisted delivery and caesarean section delivery, if needed. To reduce the cost of accessing maternal health services, the scheme provides transportation cost and cash incentives to mothers for safe delivery (either in a facility or at home but with assistance from skilled personnel). The programme started in phases in 2006 and currently it is in operation in 53 upazilas (sub-districts) located in 41 districts of Bangladesh. The scheme provides direct subsidies to the target group to enable them to obtain specific services from designated public and private health care facilities. Although it is a demand side financing programme, the current design is actually a mixture of conditional cash transfer for utilization of maternal health services (the demand side) as well as cash incentives for public sector service providers (the supply side).

b. Identifying the poor: the official criteria and distribution of vouchers According to the official manual of the program, three criteria are used to identify poor households. (i) Monthly income of Tk. 3,100 or less, (ii) Amount of land owned by the household is less than 0.15 acre, (iii) Household does not own any income earning assets like livestock, poultry, fish farm, orchard, rickshaw and rickshaw van, etc. Official system of determining eligibility in DSF-MHVS is shown by a schematic diagram in Figure 1. Although it is not clear how exactly these criteria are supposed to be implemented, it appears that the programme implementers interpret the criteria as simultaneous satisfaction of all three conditions. Using a fixed level of money income for identifying the poor is problematic for a number of reasons. Size of the household, price inflation over the years, etc. affect the poverty line but the programme did not change the poverty income level for a number of years. It should be noted that if price index is used to correct for upper poverty line of Bangladesh, poverty line in 2016 should be about Tk. 6,700 per month per family of three implying that the programme defined poverty income is much lower than the poverty line for Bangladesh. There are additional conditions which must be satisfied for enrolling beneficiaries in the programme. The beneficiary must be a resident of the upazila and the pregnancy must be either first or second order pregnancy. In case of second pregnancy, use of family planning methods prior to the pregnancy has been listed as an additional requirement. In practice, the programme uses an informal approach of identifying the beneficiaries. Field level Family Welfare Assistant (FWA) or Health Assistant (HA) or Skilled Birth Attendant (SBA) enrols eligible pregnant women using the poverty criteria by completing a registration card. Union DSF committee approves the registration by counter-signing the card and sends it to the upazila for voucher allocation and distribution. At the upazila level, the QMs verify the eligibility of few randomly 3

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS) selected registered women. Once verified, the voucher book is issued and the woman can get the book either from the upazila health centre (UHC) or from FWA, HA or SBA at the community level. Figure 1: Official Method of Identifying the MHVS beneficiaries Pregnant woman (resident of the upazila) Criteria for defining “poor”  Household income: < Tk 3100/ month  Functionally landless (<0.15 acre of land)  Does not have any other productive asset

Woman not poor

Woman from poor household

First pregnancy

Second pregnancy

Used family planning prior to the pregnancy

Third or higher order pregnancy

Did not use family planning methods

Beneficiary of MHVS

c. Management of the voucher scheme The programme is managed and implemented through a number of committees and sub-committees. At the national level, there is a National DSF Steering Committee, National DSF Programme Implementation Committee and a DSF Technical sub-committee. At the district level, District Designation Body for the selection of private hospitals/clinics chaired by the Civil Surgeon (CG) manages selection and accreditation of health care providers for participation in the scheme. Two committees are created at the upazila level, the Upazila DSF Committee and the Upazila Seed Fund Committee, both chaired by the Upazila Nirbahi Officer (UNO: the Upazila Officer in Charge). Each of the unions within the upazila has a Union DSF Committee chaired by the Union Parishad (Union Council) Chair. Membership of these committees with their responsibilities can be found in a recent report (Farzana, March 2014).

d. Flow of funds and fund transfer mechanism The DSF-MHVS is implemented by the Ministry of Health and Family Welfare (MOHFW) using pool fund which includes GOB development budget money and contributions by development partners. The flow of funds for DSF-MHVS from the Ministry of Finance to the lowest level can be summarized as follows. The pool fund budget is transferred to an account titled ‘Maternal Health Voucher Scheme’ (MHVS) operated by Line Director (LD) 4

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) of Maternal, Neonatal, Child and Adolescent Health (MNCAH). DSF administrators reported that the release of funds from the Ministry of Finance (MOF) to the MOHFW takes some time, usually about two months, after the acceptance of the budget. The release of funds from the MOHFW to the MHVS account requires development of detailed plan for the programme. Once the plan has been finalized and approved by the MOHFW and the World Bank, money is transferred to the MHVS account of the LD. From this account, funds are transferred in instalments to MHVS Upazila account at the upazila branch of Sonali Bank. The Upazila Health & Family Planning Officer (UHFPO), on behalf of the Upazila DSF committee, operates the account. The seed fund account is also created at the upazila level with an initial one-time payment of Tk. 65,000. This fund is supposed to be used to buy medical and surgical requisites or other instruments and supplies needed for the provision of maternal health services. From the upazila MHVS account the payments for private and public sector providers (for services provided to MHVS mothers) are transferred to the seed fund account. Private providers are paid based on a pre-defined payment schedule for the services delivered. Public sector health care providers also receive incentive payments but the payment received by public providers per unit of service is half of the price indicated for the service in the payment schedule. Since public sector providers are full-time government employees, the payments they receive for delivering maternal health services are designed to encourage provision of quality maternal health services to voucher holders. The remaining half of unit prices goes to the public sector facility to help improve availability and delivery of maternal health services, including drugs and supplies. Figure 2: Flow of Funds from Centre to Health Care Providers and Voucher Holders

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

e. Benefit Package and Payment Rates for Voucher Holders and Health Care Providers The voucher book allows the beneficiaries to receive a number of benefits. The benefit package consists of three ANC visits, one PNC visit, safe delivery including caesarean delivery and services needed to deal with pregnancy and delivery related complications. The voucher holders are supposed to get these services without any out-of-pocket expenses. To encourage poor pregnant women to obtain services from health facilities, the programme pays a fixed amount of money for travel expenses per trip to obtain the services included in the benefit package. Therefore, the beneficiaries can receive travel expenses for maximum of five trips (three ANC, one PNC and one trip for delivery). In addition, mothers also get incentive payments for safe delivery, although the incentive amount to be paid depends on whether the safe delivery happened in the home of the beneficiary or in a health facility. This part of MHVS payment schedule can be considered the demand side financing component. The benefits MHVS participants are supposed to receive are listed in table 1. Table 1: Benefit Package for Voucher Holders Services and benefits

Payments expected from beneficiaries Incentive payments to for service beneficiary Three ANC visits None None* Laboratory tests: blood and urine None None* Safe delivery in facility (includes normal Diagnostic and lab tests not Tk. 2,000 deliveries, vacuum or forceps deliveries and mentioned as part of benefit package C-section deliveries) were probably charged to beneficiaries Safe delivery at home None Tk. 500 Delivery complications None None* Referral to upper-level facilities None None* One PNC visit None None* Travel expenses (travels related to ANC and Actual travel expenses paid out-ofTk. 100 per trip, maximum of PNC visits, safe delivery in facility) pocketâ&#x20AC; 5 trips * This refers to incentive payments related to utilization of services, not travel or other expenses associated with the receipt of services, which are listed separately â&#x20AC; Beneficiaries pay travel expenses out-of-pocket for seeking care from facilities. They are supposed to receive Tk. 100 per trip from the programme irrespective of actual travel costs incurred. The voucher holders can obtain services from approved public sector and private sector health facilities if private providers are approved for service delivery in the upazila. Since the beneficiaries are supposed to get the services free of charge, the programme needed a mechanism of paying the private health care providers when they provide services to voucher holders. Paying the providers requires prospectively defining unit prices for each of the covered services in the DSF-MHVS. In order to encourage provision of service by private health facilities, the prices must be appropriate for the services to be offered. It is not clear how the programme came up with the unit prices or costs and how appropriate the prices are. Public sector health facilities are funded by the GOB and they are expected to provide all necessary maternal and child health services free of charge irrespective of participation in voucher programme. Therefore, unlike the private sector, public sector providers do not require additional payment for the services they provide. The programme, in order to incentivise public sector health care providers to participate in the programme and to offer quality maternal health services to the disadvantaged population groups, a payment schedule was developed for public sector service providers as well. Public health facilities also receive additional incentive payments to participate in the MHVS. Table 2 shows the unit prices set by the programme for paying public and private sector providers and the amount paid out to health care workers who actually provided the services to DSF-MHVS beneficiaries. For private sector, the money to be paid to actual health care providers is not mandated and so the private sector can negotiate the fee to be paid to providers for each type of the services covered under the programme.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Table 2: Unit Prices in Taka for Public and Private Sector Facilities Services Registration of participant ANC visit Urine test (two allowed) Blood test (two allowed) Normal delivery Medicine (total) Vacuum/forceps delivery C-section delivery Eclampsia management PNC visit Referral of a case Administrative expenses Payment for UHFPO Payment for RMO Payment for office staff

Public facility/Providers Unit price Providers get 20.00 20.00 50.00 25.00 35.00 17.50 35.00 17.50 300.00 150.00 100.00 0.00 1,000.00 500.00 6,000.00 3,000.00 1,000.00 0.00 50.00 25.00 0.00 0.00 Tk.50/delivery Tk.50/delivery Tk.60/ day

----

Private facility/Providers Unit price Provider share --50.00 No set rule 35.00 35.00 300.00 1,000.00 6,000.00 1,000.00 50.00

----

As shown in table 2, payments for each health care provider are clearly defined for the public sector health workers but it is not defined for the private sector. Private sector facilities receive the total unit price per service type and then the facilities decide how to apportion the money to different health care providers and support staff. In public sector health facilities, providers receive Tk.17.50 per laboratory test and the money is paid to the health care worker conducting the test. The payment for ANC goes to ANC visit providers (either FWV, CSBA, doctor or nurse). For home based normal delivery, the health care provider gets Tk.75 while the total money allotted for normal institutional delivery (Tk.150) is divided among the health workers involved (Tk.60 for the doctor, Tk.40 for nurse, Tk. 25 for wardboy or female helper). For conducting the C-section in a public sector health facility, the surgeon conducting the C-section gets Tk. 1,100 and the anaesthetist gets Tk.600. Tk.500 goes to operation assistant, Tk.250 each to two senior nurses, Tk.100 each to two ward-boys or female helpers and Tk.100 for the cleaner. Delivery complication related payments are Tk.300 for doctor, Tk.100 for nurse, Tk.50 for wardboy or female helper and Tk.50 for cleaner.

Results of the Diagnostic Study a. Issues and Concerns identified by other studies

A number of studies were reviewed to understand various issues and concerns identified by these reports. Most of the studies concluded that the DSF-MHVS has significantly improved access to maternal health services for the voucher holders and utilization of ANC, safe delivery and PNC have increased in the DSF areas and among voucher holders (Rannan-Eliya, Technical Report B, 2012; Farzana, March 2014; Halim, March 2014; Anwar, Blaakman, & Akhter, September 2013; Hatt, et al., February 2010; Ahmed & Khan, 2011; Noor, Talukder, & Rob, 2013). Equity in maternal health service utilization also improved in the DSF areas compared to similar non-DSF areas although one study did not find any effect on equity (Rannan-Eliya, Technical Report B, 2012). This specific study, however, tried to derive equity implications through patient surveys carried out in health care facilities, which is not the recommended approach of evaluating equity implications of a programme. The programme has also improved utilization of Upazila Health Centres (UHCs) in DSF areas implying that public sector health care delivery system can be strengthened through the voucher scheme (Noor &

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Rob, Does Maternal Health Voucher Scheme Have an Impact on Out-of-pocket Expenditure and Utilization of Delivery Care Services in Rural Bangladesh?, 2013). The studies reviewed identified a number of issues and concerns related to the implementation and functioning of the DSF. These issues are summarized in the paragraphs below. (i)

Administrative and management issues: MHVS implementers at the upazila and union levels sometimes did not know the details of the programme implementation and the benefit package of voucher holders. Consistent policies were not followed in all geographic areas in the identification of poor pregnant women. One study reports that at the initial stage of MHVS implementation, some upazilas misunderstood the enrolment criteria and enrolled individuals who should not have been in the programme (Ahmed & Khan, 2011). Lack of communication between the programme management at the centre and local level implementers was considered a significant concern. Some studies also mentioned that union level DSF committees were not functional in some areas. The orientation trainings organized at the local level were not very effective (Koehlmoos, et al., September 2008).

(ii)

Financial issues: Significant delay in the payment of the incentives to beneficiaries is a major concern. This problem was identified by almost all studies evaluating the DSF programme (Hatt, et al., February 2010; Ahmed & Khan, 2011). More recent studies also report delay in fund disbursement as an important threat to the programme (Anwar, Blaakman, & Akhter, September 2013). The delay probably varies from year to year but the usual delay appears to be in between three to six months (Anwar, Blaakman, & Akhter, September 2013). One study reported that the funds for the programme are released only twice a year and in one year the first instalment was not even transferred to the Ministry of Health before December (Farzana, March 2014; Koehlmoos, et al., September 2008). Delay in the flow of funds happen at all levels, adversely affecting the efficient functioning of programme activities. Sending the unspent money back to the central treasury at the end of fiscal year creates further delays in fund disbursement to beneficiaries (Sabur, December 2015).

(iii)

Target group identification: The MHVS defines the eligibility criteria for enrolment in the programme but eligibility criteria are not often followed (Hatt, et al., February 2010). In some cases, vouchers were distributed to individuals who were not eligible (Koehlmoos, et al., September 2008). All pregnant women are supposed to be identified and brought into the programme during the first trimester. One study reported that pregnant women were enrolled in the programme as late as eight to nine months of pregnancy. The requirement that the pregnancy should be either first or second for the women was not adopted in some cases (Koehlmoos, et al., September 2008). The poverty income defined by the programme is also considered unrealistic, given the improvements in economic status of population in Bangladesh and the overall price inflation over the years (Anwar, Blaakman, & Akhter, September 2013). Although the studies indicated the possibility of mistargeting, none reported on the degree of mistargeting in the programme.

(iv)

Quality of health care services in DSF areas: One study has examined technical and clinical quality for DSF and non-DSF area health facilities. Although the sample size is quite small, the study provided some idea about relative quality of facilities using quality monitoring checklist (Anwar, Blaakman, & Akhter, September 2013). Quality of care index was found to be higher in DSF facilities than in non-DSF facilities. Only 50% of facilities in DSF area were found to be Comprehensive Emergency Obstetric Care (CEmOC) facilities. Lack of specialist doctors, obstetrics and anaesthesiologists, was found to be an important concern (Koehlmoos, et al., September 2008; Anwar, Blaakman, & Akhter, September 2013). Not using partograph on a routine basis has

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS) also been reported as a significant problem in both DSF and non-DSF health facilities, especially because caesarean section deliveries are increasing rapidly over the years. (v)

Knowledge of voucher holders about the benefit package and about DSF-MHVS in general: One study indicates that the DSF program is weak in terms of community mobilization and providing relevant information to pregnant women and to future potential beneficiaries. Even the voucher holders did not know all the services that are entitled to under the programme (Anwar, Blaakman, & Akhter, September 2013).

(vi)

Out-of-pocket (OOP) expenses of voucher holders: Noor et al. used a difference in difference approach to estimate the effect of DSF-MHVS on out-of-pocket expenses for accessing maternal health services. They found that in the DSF intervention areas, average OOP cost for normal delivery declined by 16% while it declined by 37% for caesarean delivery compared to the expenses in control areas. Survey of facility users did not find lower out-of-pocket expenses in DSF upazila health centres (Rannan-Eliya, Technical Report B, 2012). The studies, however, implies that the services were not obtained free-of-charge by voucher holders.

(vii)

Provider payment and supplier induced demand issues: One concern raised by a number of studies is the possibility of over-utilization of caesarean section delivery due to high level of incentives given to the surgeon compared to what the doctor gets for a normal delivery. In the public sector, doctor receives only Tk. 60 per normal delivery and Tk. 1,100 for C-section delivery. The C-section delivery incentive amount is more than 18 times of the normal delivery incentive at the facility level. The information reported by the studies indicate much higher rate of C-section delivery in DSF areas compared to other comparable areas (Anwar, Blaakman, & Akhter, September 2013; Farzana, March 2014; Noor & Rob, Does Maternal Health Voucher Scheme Have an Impact on Out-of-pocket Expenditure and Utilization of Delivery Care Services in Rural Bangladesh?, 2013).

b. Opinion of policy-makers and key informants The team discussed with a number of policy makers, representatives of development partners and field level implementers to identify potential issues and concerns. At all levels, the key informants were of the opinion that DSFMHVS has improved access to maternal health service by pregnant women, especially for poor women in the DSF areas. Most believe that the programme should be strengthened and scaled-up to improve maternal health status in Bangladesh. The discussions with different stakeholders identified following issues or concerns. 

Budgetary process and Annual Development Program (ADP) allocation is time consuming. The time lag between start of fiscal year and actual budgetary allocation to MOHFW could be about 3-6 months. This delay creates significant obstacles in running the DSF-MHVS.



Since the DSF fund comes from the development budget, after the beginning of the financial year MOHFW releases quarterly allotment in favour of LD. LD then send advance drawing request to MOHFW, which then is sent to MOF for approval. The approval then comes back to LD. The LD submits bill to Accountant General (AG) office for drawing the fund. Thereafter, fund is disbursed to UHFPO’s MHVS account. This process may take few additional months.



Advance is required for payment of cash incentive, travel allowance, etc. The programme should develop a mechanism to get advance on a timely basis for continuing the essential operations of the programme.



Paying mothers through bank accounts appears to be not working as planned. In most areas, bank managers are not interested to open accounts for the poor women as it is perceived to be one-time banking only with significant administrative costs involved. The requirement of getting a cell phone number for the beneficiaries in order to transfer money to the bank account has also become an issue.



Incentive money is not paid on a timely basis to beneficiaries. They often have to travel a number of times to the upazila to get their money. This creates dissatisfaction among the DSF-MHVS enrolees. 9

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS) 

The programme should consider a number of options for disbursing money to beneficiaries including online banking, e-cash transfer system, use of postal money order, etc. This will allow disbursement from the centre without the need for going through the upazila account.



There are too many DSF committees. The number of committees can be reduced and the number of DSF meetings can also be reduced by combining DSF discussions with other meeting agenda items at union and upazila levels.



Third party should be involved for ensuring quality of services delivered, improved management and transparency of the programme and reimbursing health care providers for the services delivered. Involvement of the third party will create internal checks and balances within the system.



The administrative cost of the programme is high and there appears to be significant mismanagement within the system.



Human resource availability should be ensured before the programme encourages mothers to come to facilities for the delivery of babies. More than half of the DSF facilities are not ready to provide CEmOC services.



Criteria used for identifying the poor are not appropriate. These should be revised to reflect the current poverty situation and poverty level income.



Identifying the poor and targeting the poor pregnant women is not working. The question is whether the programme will be more efficient if it is converted into a universal coverage programme.

c. Field visits: Opinions from the field The first field visit took place in Daudkandi upazila, Comilla. The team visited the Upazila Health Complex (UHC), the private hospital contracted by DSF in the area and a village (Village: Shobibad, Union: Baro Para) in the upazila. At the UHC, the team members met with the Upazila Health and Family Planning Officer (UHFPO), Resident Medical Officer (RMO), gynaecological consultants and the anaesthetics. The purpose of the discussions was to better understand the services delivered and issues/concerns with delivery of maternal health services from the UHC and from other lower level health facilities. During the field visit, data were collected on service delivery from the UHC. During January 2016 to August 2016, number of ANCs used at UHC was 458 for voucher holders and 3,115 for non-DSF cases. Therefore, 13% of all ANC services provided at UHC were given to the DSF voucher holders. During this eight month period, DSF voucher holders accounted for 19.5% of all normal deliveries at the UHC (122 deliveries out of 627). From January-August 2016, total number of Csections done at the UHC was 118 and out of this 84 cases were DSF voucher holders (71% of all caesarean sections done). Among the mothers delivering in UHC, C-section rate was 40.8% for DSF voucher holders and 6.3% among non-DSF pregnant women. Large difference in C-section rates between DSF and non-DSF mothers indicate possible effect of monetary incentives on clinical decision-making. This comparison may be biased due to a number of other possible reasons: (i) non-DSF women with complicated pregnancies and/or requiring caesarean sections may prefer to use private health care facilities, (ii) DSF voucher holders with complicated pregnancies are encouraged to use UHC by health care providers. Interview with the owner of the private hospital in the area indicates that the private sector usually charges about Tk. 9,000 to 12,000 for a C-section delivery and Tk. 3,000 to 4,000 for a normal delivery in this rural community. The prices they receive under DSF-MHVS for the services delivered are lower than the “market prices” for private patients. According to the private facility manager/owner, they do not charge anything extra for the services delivered and they accept the DSF payments as the total payment for the services. Some beneficiaries, however, mentioned that the private hospital charged

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) extra money. Some mothers also mentioned that they had to buy some drugs and supplies while receiving services from UHC and private health care providers. It was clear from the discussions with the beneficiaries in project areas visited that mothers and their family members were concerned about the pressure doctors exert on pregnant women to undergo caesarean delivery. All the beneficiaries the team met in the villages received the incentive and travel money together in one instalment in Daudkandi only few weeks prior to the field visit in early October. They also complained that the bank managers do not want to see them in the bank because the children make â&#x20AC;&#x153;noises or cryâ&#x20AC;? annoying the manager and the clients of the bank. If housing condition and ownership of assets are considered, none of the participants (including a newly enrolled woman interviewed) appear to be from poor households (almost all lived in houses with tin-roof, cement floor and tin walls, houses had electricity and connected to gas supply line.). In the second field trip to Sarishabari upazila of Jamalpur district, the team discussed MHVS with the Civil Surgeon (CS) at the district level. The CS was not involved with the day to day operational and management aspects of the programme. No report goes through the CS despite him being the district health authority and chairperson of the DSF technical committee. District committee did not meet at all in the previous one year. The CS suggested that the upazila DSF committee should be chaired by the UHFPO rather than the UNO. Upazila and union level DSF committees were also found to be not functional and have met only few times during 2015 in both the areas. The team members talked to four pregnant women in Sharishabari who have come to the UHC for obtaining ANC. All four were in their 3rd trimester of pregnancy, although that was their first visit as DSF-MHVS mother. Recruiting pregnant women at this late stage implies problems with programme implementation as well as lack of awareness of pregnant women about the programme. Four recent beneficiaries were interviewed in a village and none of these beneficiaries received their travel money or incentive payments at the time of the field trip. These DSF beneficiaries were also not poor if housing and amenities available are considered. Therefore, the enrolment criteria may not have been followed in registering the women in DSF-MHVS. The programme participants in this area reported that they had to buy drugs and supplies themselves for caesarean section and pregnancy complications.

d. Survey of WHO Quality Managers (QMs) This study took advantage of the presence of WHO QMs in Dhaka for their annual training session to carry out a quick survey. A structured questionnaire was used to collect information on specific areas of concerns and issues (see Annex B for the questionnaire). The QMs were asked to list three most important current concerns of the DSF-MHVS programme and the concerns listed are shown in Table 3. About 65% of the QMs thought that the new system of distributing money through bank accounts was not working. Mothers had to travel to bank a number of times, had to fill a long form to open an account, banks often were not interested in opening the account and costs associated with cashing cheques were high (due to the cost associated with getting the cheque book, etc.). Non-availability of clinical personnel in health facilities has been mentioned by 50% of survey participants. 46% mentioned flow of funds as one of the major concerns and about 20 to 25% mentioned other issues and problems. Table 3: Three most important issues and concerns as identified by the WHO QMs Money disbursement through bank accounts have become problematic Skilled personnel not available at health facilities Problems and concerns with regular/timely flow of funds for the program 11

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Lack of communication among village, union and UHC program personnel UHFPO not interested, lack of accountability Gynaecology and anaesthesiology pair not available Other important results are: 85% mentioned that independent verification of poverty status of voucher recipients are carried out by the QMs on a regular basis, on the average 74% of poor pregnant women receive vouchers, 77% of participants are poor, 100% of health care providers and almost 100% of beneficiaries eventually receive the incentive money, average delay in getting funds is about eight months, 60% of the areas do not provide new-born incentive funds anymore and those who provide incentive funds, none provides it on a timely basis. Regarding the incentive payments, the survey participants mentioned that there was no difference in time-lag between government and private providers or between relatively better-off or poor beneficiaries. Most frequently mentioned reforms or changes were: 

Regular flow of funds should be ensured, delay in disbursing funds is a significant concern



Transferring money through banks is not working. The programme should consider disbursing money to beneficiaries through Bikash, postal or other e-cash system



Women should get their travel reimbursement at exit from the facility. They should also get their incentive payments at exit after delivery and within few days in case of home delivery



DSF should ensure availability of right mix of health care providers



Monitoring and supervision should be strengthened. In some areas, the UHFPO does not show any interest in the programme



Improve understanding of mothers about the program to help in the recruitment of eligible women as well as making women aware of the benefits of MHVS



Poverty criteria as defined are difficult to implement and verify

e. Analysis of Programme Data This section presents results of the analysis of administrative or programme data. There are two different data sets that were obtained. One data set reports the monthly utilization of different types of services by DSF-MHVS beneficiaries and the second data set presents budget and cost numbers since 2011.

(i)

Maternal health utilization pattern

Figure 3 shows the number of vouchers distributed in different years since 2011 and the number of safe deliveries conducted among the MHVS beneficiaries. The number of voucher books distributed as well as the number of safe deliveries conducted among DSF mothers have declined in recent years. The decline in DSF-MHVS participation should not be interpreted as decline in the demand for DSF programme. The principal reason for the decline in the number of DSF voucher holders in 2015-16 is the way the target numbers are calculated for the upazilas. In 2014-15, target number of pregnant women was calculated by assuming a Crude Birth Rate (CBR) of 2.6 per 100 population and then 50% of pregnancies were considered eligible. From June 2016, CBR was changed to 2.2 and it was assumed that 40% of pregnancies will be eligible. This adjustment reduced actual target number by 10% but the voucher distribution declined by 27%. With full implementation of this target calculation over a full year, target number is expected to decline by 32% compared to 2015-16. The change in the target calculation may have created uncertainty at the field level producing much sharper decline in voucher distribution than the rate of decline of target numbers. Even the new CBR used by the programme to calculate 12

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) the target numbers is higher than the average CBR of the country in 2016. In addition, the programme assumed that 40% of pregnancies as eligible for DSF-MHVS, which is likely to be higher than the proportion of pregnant women poor in these 53 upazilas. This assumption further inflates the number of women eligible for participation in DSF-MHVS. Therefore, the target calculation, even after the recent corrections, overestimates the target population and communicating these target numbers to programme implementers at the upazila level may encourage enrolment of non-eligible women in an effort to move closer to the target numbers.

Figure 3: Target numbers, voucher books distributed and number of safe deliveries among DSF participants by year 220000

206153

201756

200000

182458

180000 160000

155289

152401

158545 145900

140000 120000

129929

130509

107021

129194 116370

100000 80000

79015

60000 2011-12

2012-13

Voucher distributed

2013-14 No. of safe deliveries

2014-15

2015-16

Target No.

Figure 4 shows the utilization of maternal health services by the voucher holders. Due to lower enrolment in the programme in 2015-16, utilization of various services, in absolute terms, also declined in the year compared to the previous years. Vouchers distributed as a percent of target were around 72 to 79% for all years excepting 2015-16 when it declined to 59%. Proportion of voucher holders selecting safe delivery methods varied from 74% in 2015-16 to 86% in 2012-13.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Figure 4: Utilization of ANC, PNC and Delivery Services by MHVS mothers 160000 140000 120000 100000 80000 60000 40000 20000 0 2011-12 2012-13 2013-14 2014-15 2015-16

ANC1 138658 136592 141363 135613 97311

ANC2 127430 124564 133561 125660 86590 2011-12

2012-13

ANC3 114013 112731 119011 110021 72434 2013-14

2014-15

Safe delivery 129929 130509 129194 116370 79015

PNC 124564 125974 125103 111353 75174

2015-16

Figure 5 shows the C-section rates by DSF upazilas. The rates were calculated using number of safe deliveries as the denominator (number of C-section deliveries as percent of total safe deliveries among voucher holders). The C-section rates in 2015-16 varied from zero percent to more than 45%. In 12 upazilas under DSF-MHVS, the C-section rates were more than 25%. It should be noted that a significant proportion of voucher holders drop out from the programme and details on these pregnant women are not available in the administrative data set (as they did not utilize DSF-MHVS benefits). Figure 5: C-section delivery rates for DSF beneficiaries by Upazila (percent of DSF safe deliveries in the area)

50 45

C-section rate %

40 35 30 25 20 15 10 5 0

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) The upazilas where the C-section rates were very high, higher than 25% of DSF-MHVS participants in 2015-16, are listed in Table 4. The table also reports whether the upazilas had gynaecology and anaesthetist pair in the UHC for all the 12 months in the year and whether there is at least one private facility contracted by DSF in the area. It is interesting to note that not all upazilas with high C-section rates had the pair present for the whole year. In fact, in some of the upazilas, the health care provider pair were absent for all 12 months. For example, in Fakirhat, the gynaecologist was present for 10 months but the anaesthetist was not present at all implying absence of the pair for the whole year. Despite this, the upazila shows the second highest rate of C-section deliveries. In Ulipur, neither the gynaecologist nor the anaesthetist was present although it is possible that the pair was present in the private sector provider contracted by DSF-MHVS in the area. Table 4: List of upazilas with high rate of C-section delivery rates (>25%), presence of gynaecology-anaesthetist pair and involvement of private sector, 2015-16 Upazila Sreemangal

Pair present all 12 months? Yes

Private sector contracted? No

C-section rate (% of safe deliveries) 27.7

Kalia

Yes

27.9

Shyamnagar

Yes

28.1

Chatkhil

Yes

28.3

Khetlal

Yes

28.3

Ukhia

Yes

28.9

Ulipur

Yes

31.5

Chawgacha

Yes

33.0

Atrai

34.6

Raipur

Yes

35.4

Fakirhat

37.7

Mirsharai

YES

Yes

45.6

(ii) Expenditures on maternal health services and incentives for beneficiaries Using the utilization of various services and unit prices of services, it is possible to calculate the total money needed for paying for the health care services used by the voucher holders. The costs are estimated only for one year â&#x20AC;&#x201C; the fiscal year 2015-16. The costs include the payments for health care providers as well as the incentive payments offered to programme beneficiaries. The estimates reflect the cost the programme would have incurred for incentive payments and reimbursements for services if all the payments were made according to price/incentive schedule of the programme. The cost estimates presented here may overestimate the actual expenses slightly due to non-availability of few relevant information. For example, utilization data do not report source of ANC and PNC services. If the ANC and PNC services are obtained from the FWA at the community level, pregnant women are not entitled for travel cost. In this estimation, we have assumed that all ANC and PNC services were obtained from health facilities. Another service category not reported in the data set is the number of facility based delivery numbers. Only for recent few months, the number of deliveries is reported by place of delivery. The proportion of all deliveries happening in health facilities for the months March to August 2016 was used to estimate the total facility births for the whole year 2015-16. For all the 53 upazilas taken together, 41.35% births happened at home, 53.95% births happened in public health care facilities and the remaining 4.7% happened in private facilities.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Table 5 reports the budget needed to pay the health care providers and the beneficiaries for all the maternal health services provided to voucher holders. The unit prices mentioned in table 2 were used to calculate the total budget needed to pay for the services, travel expenses and incentive payments. Given the utilization of maternal health services, total budget needs become Tk.124.1 million for paying for the services provided by the health care personnel. The most important cost item in provider payments is the cost of caesarean section delivery, which represents about 59% of total health service expenses. The second-most important expenditure category is the payment for normal deliveries. Cost of service provision can be reduced significantly if the caesarean section rate can be reduced. The budget needs for 2015-16 to pay the beneficiaries their incentive payments were about Tk. 149.1 million. Institutional delivery related incentives represent about 62% of total payments to voucher holders and additional 11% was paid for safe home deliveries. The administrative cost at the facility level, which includes incentive payments for UHFPO and RMO at the UHC and salary payment for one office staff per UHC, is estimated at Tk. 5.6 million. Therefore, total service-related expenses amount to Tk. 278.7 million. Table 5: Estimation of budget needs to pay for maternal health services in 53 DSF upazilas of Bangladesh for the year 201516 Total number of vouchers distributed in the year Number of safe deliveries conducted in the year

Expenses for paying providers Registration ANC 1 expenses ANC 2 expenses ANC 3 expenses Blood test 1 Blood test 2 Urine test 1 Urine test 2 Normal Delivery C-section delivery Vacuum or forceps delivery D&C Eclampsia case related PNC expenses Payment for UHFPO/ RMO Office staff

107,021 78,905

In taka 2140420 4865550 4329500 3621700 1664040 1232595 1666735 1234415 26700000 72600000 203000 10000 42000 3758700 4627778 992160

Expenses for paying beneficiaries Travel reimbursement, ANC/PNC Travel reimbursement, delivery Institutional delivery incentive Home delivery incentive Referral related travel cost

Total service related cost to be paid to 124,068,655 providers Administrative cost for facility 5,619,938 managers Total cost: facility related 129,688,593 Total cost: Beneficiary payments Total cost needed to pay health care providers and beneficiaries of the programme

In taka 33200000 4627778 92600000 16300000 2323500

149,051,278 278,739,871

If the voucher books are distributed evenly over the year and if all pregnant women are enrolled in the programme within the first trimester (say at three months of gestation), number of deliveries conducted in a year should be approximately equal to the total number of vouchers distributed. Therefore, to find the cost parameters of the programme for calculating

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) total cost under different scenarios, we can use the number of vouchers distributed as the denominator for service-related expenses. For incentive payments to UHFPO and RMO, the relevant denominator should be the number of institutional deliveries. Administrative expenses should use the number of upazilas in the programme as the denominator. Number of vouchers distributed will depend on gross fertility rate, poverty rate and the percent of total births that is first order and second order births. Therefore, the cost parameters of DSF-MHVS for delivering maternal health services in 2015-16 should be as follows: Provider payments for the services delivered:

Tk. 1,181 per voucher distributed

Paying beneficiaries for travel and incentives:

Tk. 1,371 per voucher distributed

Paying UHFPO and RMO for delivery cases:

Tk. 100 per institutional delivery

Office staff wage payment:

Tk. 18,720 per upazila per year

(iii)

Programme Budget and Expenditure as reported by MHVS

Paying for the health care services are not the only expenses the programme incurs in running the activities of DSF-MHVS. To estimate other expenses, we can examine the budget and expenditure numbers reported by the programme over the last few years. Annex C reproduces the budget and expenditure numbers for the years 2011-2016 and the average expenses per year over these five years after adjusting the budget and expenditure numbers for inflation using the Consumer Price Index of Bangladesh (BBS, September 2016). According to the budget and expenditure levels reported, average annual budget of the programme was about Tk. 12.674 million per upazila or Tk. 671.72 million per year for the programme in 53 upazilas. Excluding the expenses related to payment for services and incentive payments for beneficiaries, the remaining expenses becomes Tk.13.21 lac or Tk.1.321 million per upazila. These additional expenses include postages, printing and publications, stationaries and office supplies, publicity and advertisement, training, orientation meetings, transportation costs for project personnel, medical supplies, copying, committee meetings, computers and other expenses. It is interesting that over the last few years there were virtually no expenditures on office supplies, publicity and advertisement. Field level implementation personnel as well as potential beneficiaries should be made aware about the various aspects of the programme including the benefit package provided by the programme to the beneficiaries. To improve knowledge of participants about the programme, it is important to use some resources on advertisement, behaviour change communications, trainings, etc. Based on the average budget numbers, it is assumed that publicity and training of providers should cost about Tk. 0.10 lac per year for the programme.

(iv)

Other expenses not in the budget

One additional cost component not included in the budget or expenditure numbers of the programme is related to overall management and implementation of MHVS. A number of Ministry of Health personnel are involved with the programme and additional personnel are appointed by the World Health Organization (WHO). Since the programme requires the presence of these administrative and operational personnel, the programme should consider the value of their time as important cost items. In the field visits, it was clear that the MHVS will not work effectively if the WHO QMs are not there at the upazila level. The cost calculations are shown below: Time allocated by MOHFW personnel: 10% each for three personnel (Line Director, Deputy Director and programme manager, assistant director and deputy programme manager, finance and administration) plus 100% time of deputy programme manager, DSF. Value of time MOHFW personnel, per month = 0.1(Tk.71,500+65,500+54,500)+ (54,500) = Tk. 73,650 17

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Value of time of WHO appointed personnel to DSF = 1,17,000+ 2*(89,000) + 27* (60,000) = 1,915,000 Annual administrative and implementation cost out-of-budget of MHVS = (Tk. 73,650+Tk.1,915,000)*12 month = Tk. 23,863,800 Annual administrative and implementation cost per upazila = Tk. 450,260 Parameters for other cost items and personnel cost for management and implementation of the programme are listed below. Expenses on meetings, printing, supplies, copying, etc.:

Tk. 1.321 million/upazila

Expenses related to advertisement/publicity:

Tk. 0.10 million/upazila

Additional personnel cost for management/ implementation:

Tk. 0.45 million/upazila

f. Targeting Efficiency of MHVS (i)

Measuring targeting efficiency

Two measures of targeting efficiency can be used to understand how efficiently the programme identifies the target population for inclusion in the programme activities. Assume that the population (pregnant woman) in an area is N. There are two mutually exclusive groups of pregnant women: poor Np and non-poor Nnp. The number of individuals enrolled in MHVS is B and the enrolees are either from poor households, Bp, or from non-poor households Bnp. Using these notations, we can define the targeting efficiency measures as: Proportion of poor women in the programme T1 =

đ??ľđ?&#x2018;?

Proportion of poor enrolled in the programme T2 =

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Ăˇ

đ?&#x2018; đ?&#x2018;? đ?&#x2018; đ?&#x2018;? +đ?&#x2018; đ?&#x2018;&#x203A;đ?&#x2018;?

The first measure shows what fraction of programme participants are poor and the second measure shows what fraction of poor people are actually enrolled in the programme. The second measure is affected by proportion of poor women in the programme (T1), size of the program (proportion of population enrolled) and the proportion of population poor. From national data we can approximately derive proportion of pregnant women poor in the upazila and the proportion of population enrolled in the programme but there is no information on the proportion of pregnant women poor among all women enrolled. The field visits conducted by the team members indicate that the proportion of enrolees of the programme poor is quite low. Without a community level random sample, it is not possible to derive how efficient the programme is in terms of targeting efficiency. It is unlikely that the programme will be more efficient than other social protection programmes of the country. A report found that T1 measure is probably less than 0.5 for social protection programmes that target the poor in the community (World Bank, 2013). The subjective opinion of the QMs is that about 74% of poor pregnant women are actually enrolled in the programme and 77% of all enrolled women are poor. Since QMs are in charge of verifying and cross-checking the eligibility criteria, it is likely that they would tend to overstate the proportion of poor enrolled. Given the target setting mechanism, if all target women are actually enrolled, it should represent 40% of pregnancies in the area. Since the actual enrolment is about 60% of target, percent of pregnant women enrolled would be about 24%. If T1 is 0.77 and T2 is 0.74, poverty rate among pregnant women in these 53 upazilas would be about 24%. Given the poverty rates in the upazilas, 38% of enrolled women should be poor implying that less than 50% of poor pregnant women were enrolled in the programme if 77% of enrolled were poor.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

(ii) Efficiency of geographic targeting Since targeting the poor women is an important objective of the programme, it is important to choose upazilas with relatively high poverty head-count ratio (proportion of population below the poverty line). Upazila level headcount ratio of poverty was used to indicate how efficient the programme was in targeting the poor areas of the country. Figure 6 shows the distribution of DSF upazilas by poverty status. Note that the programme selected 15 upazilas from the poorest 20% of upazilas in Bangladesh another 11 from the second poorest quintile. 15 upazilas were selected from the least poor 40% of upazilas of the country. Clearly, the selection of the upazilas was not based on geographic poverty ratio. Not choosing the poorest upazilas does not necessarily imply that the programme fails to reach the poor; how effectively it can reach the poor depends on the targeting efficiency in each of the areas. Annex A lists the MHVS upazilas by their headcount ratio of poverty.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Figure 6: Distribution of MHVS upazilas by poverty quintile of all upazilas in Bangladesh (using 2010 upazila level poverty rate estimates) 15

13.9

14 11

12 10.1

11.0 9

8.3

5.5

4 2 0 Highest poverty rate upazilas (lowest quintile)

Second highest poverty upazilas

No of DSF upazilas

(iii)

Third quintile

Fouth quintile

Lowest poverty rate upazilas (highest quintile)

DSF upazilas as % of total in the category

Enrolment if upper poverty line is used for targeting

If the upper poverty line of 2010 is used for identifying the poor pregnant women, total number of vouchers that the programme should have distributed in 2015-16 would have been 91,558 (assuming that poverty rate among first and second order pregnancy cases is 10% higher than upazila poverty rate) but the programme distributed about 107,000 vouchers. Therefore, the programme distributed 17% more vouchers than the number of poor women in the 53 upazilas. The estimates are reported in Annex A, table A2. For each upazila in the DSF programme, we started with the male and female population in 2001 and 2011. Using the inter-censul population growth rate, male and female population for 2016 was projected. Using the age distribution of women in Bangladesh, we assumed that in all the upazilas 65.39% of women are in the age group 15 to 49 years. The district level gross fertility rates were used to calculate total number of births expected in 2016, number of pregnant women poor was derived using upazila level poverty rate (plus 10%). The DHS data implies that about 63% of all births in 2014 in Bangladesh were first or second birth order (assuming equal number of second and third order births). Using this ratio, number of pregnant women eligible for participation in DSF programme was calculated. The table indicates that the number of vouchers distributed in some areas were much higher than the expected number of poor pregnant women. In Daulatpur, number of vouchers distributed was higher than what is expected based on fertility and poverty rates. In fact, the number of vouchers distributed was higher than the expected number of poor eligible women in 31 upazilas out of 53 upazilas. Since the small area poverty estimation may have some errors, this is not a definitive calculation but indicates the possibility of significant mistargeting in the DSF-MHVS programme.

VI.

Policy Suggestions a. Issues related to flow of funds

One of the most important concerns raised by all the stakeholders during discussions and exchange of ideas was the issue of long delay in the flow of funds from the GOB to MOHFW and then to other lower level entities involved with the management and implementation of the programme. At the beneficiary level, the delay in payment of incentives was around eight to 10 months. Late payment of incentives and transportation expenses go against the very purpose of

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) demand side financing which intends to improve demand for specific maternal health services by lowering the cost of accessing care. Paying the incentives after eight to 10 months will be viewed by the beneficiaries as income supplementation rather than price reduction and so the effect on utilization will be lower than the effect due to â&#x20AC;&#x153;price effectsâ&#x20AC;?.

(i)

Flow of funds from national to upazila level

Inter-ministerial communications are needed to find a mechanism for improving flow of funds from the Ministry of Finance to the Ministry of Health. Prior studies mentioned a delay of about three to six months at this level alone.

Suggestion 1: Ministry of Finance should allocate budgeted money for the programme to the Ministry of Health immediately after the adoption of the annual budget. The causes of long delay in allocating the funds should be identified and corrected. The objective should be to lower the time lag between budget adoption and payment to MOHFW to less than 30 days. The process of requesting advance for the funding of the programme is cumbersome and should be simplified.

Suggestion 2: The MOHFW should request allocation of imprest. Special permission will be required as the draw of advance for DSF-MHVS will be much higher than usual imprest.

(ii) Mode of paying the providers and the beneficiaries Our field visits as well as various studies reviewed identified delay in paying the beneficiaries as a critical concern. Paying the providers, although delayed, has not been mentioned as an important issue. The programme should devise ways to ensure timely payments to beneficiaries. A number of prior studies have discussed possible ways of improving the situation. Payment through bank accounts was adopted recently to reduce the time lag in paying the beneficiaries. Discussions during the field visits indicate that the payment through bank accounts is not working as expected. A significant proportion of women became frustrated and gave-up on the idea of opening a bank account. For paying the beneficiaries, it is important to provide wide range of options. The payments could be through bank accounts (traditional accounts, online banking accounts and any other bank accounts the beneficiaries may already have, including the accounts with NGO micro-credit entities), through postal money orders or through e-cash or mobile payment systems. Various modalities for paying the beneficiaries have been discussed in a report by Sabur (Sabur, December 2015). The programme may allow the beneficiaries to choose from a list of alternative mechanisms of paying. With bank accounts, women have to travel to the local bank a number of times just to open an account and then a number of times to withdraw the funds. The requirement of providing a cell-phone number for the reimbursement of funds to beneficiaries may also be problematic. According to DHS 2014, about 60% of poorest quintile households do not own cell phones. Paying the beneficiaries through mobile cash transfer will cost about 2% of funds disbursed, although GOB may negotiate a lower rate with the service providers due to the volume of the total funds to be transferred. The administrative cost of transferring funds should be paid by the programme and should not be subtracted from the funds to be received by the beneficiaries.

Suggestion 3: Allow beneficiaries to choose from a number of alternative ways of receiving the incentive funds and transport cost. The alternatives could be (i) regular bank accounts, (ii) online banking, (iii) micro-credit accounts, (iv) postal money order, (v) e-cash or mobile transfer of funds. The payments to beneficiaries can be done directly from MHVS account at the centre.

Suggestion 4: The system of opening bank accounts should be simplified. The application for opening an account is too long. Using traditional banking for paying DSF beneficiaries three to four times in a year may not be the most cost-effective

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) mechanism, from the perspective of the bank management and the beneficiaries (especially for those who currently do not hold any bank accounts).

b. Administration and management related issues The DSF-MHVS has defined a number of DSF committees for proper functioning of the programme. It was observed that many of the committees are not functional. For example, at the district level, the committee has little or no involvement with the day to day activities of the programme. At the union level, DSF committees met infrequently and many Union Parishad members were not aware of the activities of DSF-MHVS.

Suggestion 5: Different DSF committees may be streamlined for improved efficiency and the need for multiple committees in running the DSF-MHVS may be reviewed. Reduction in the number of committees associated with DSF-MHVS should reduce expenditures on orientation meetings, travel costs, etc. Limited involvement of government officials with DSF-MHVS implies lack of ownership of the programme by the government. At upazila level, WHO QMs have become critical in proper functioning of the programme. The DSF QMs are the only ones at the upazila level keeping liaison with upazila, union and field level health staff and beneficiaries.

Suggestion 6: For proper functioning of the programme, arrangements should be made to ensure the presence of one fulltime personnel per upazila. This administrative person will be in charge of all programme activities including verification of eligibility, keeping contacts with stakeholders and beneficiaries, coordinating data collection with upazila level Health Information System personnel, etc.

c. Paying the providers Since the services are supposed to be offered free-of-charge to the beneficiaries, the service providers, especially the private health care providers, need to be paid for the services they provide. Table 6 shows the official DSF-MHVS prices and the market price of the services in one of the rural upazila visited by the study team. If the mid-values of the private market prices are used for comparative purposes, the ratios of market to DSF-MHVS prices were 8.0 for ANC and PNC, 2.6 for lab tests, 11.7 for normal delivery, 5.0 for vacuum or forceps delivery and 1.75 for C-section delivery. Given these price ratios, private sector will have relatively high incentives to conduct C-section deliveries and laboratory tests. The gap that exists between the market price and the DSF-MHVS price also encourages imposing additional user fees on DSF beneficiaries. Table 6: Comparison of DSF-MHVS unit prices and the market prices of the services in one rural upazila (data collected from Daudkandi upazila, Comilla) Services ANC visit Urine test Blood test Normal delivery Vacuum/forceps delivery C-section delivery Eclampsia management PNC visit

DSF-MHVS price

Private market price in Daudkandi upazila

50 35 35 300 1,000 6,000 1,000 50

300-500 80-100 80-100 3,000-4,000 5,000 9,000-12,000 Price information not available 300-500

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) The payment rates should be carefully evaluated to ensure that the prices are consistent with the social objective of improving maternal and neonatal health as well as improving access to maternal health services by poor pregnant women in rural Bangladesh.

Suggestion 7: The price list for DSF-MHVS services should be carefully evaluated. The gap between market price and DSFMHVS price encourages imposition of user fees by health care providers. Systematic independent monitoring of user-fees is needed to ensure that beneficiaries are not charged extra for essential maternal health services.

Suggestion 8: The MHVS benefit package does not include some required diagnostic and laboratory tests (blood grouping, blood sugar, and ultrasound under specific situations). The programme may consider including these tests in the package. The DSF prices of these tests should be set at levels to allow recovery of cost but the DSF-MHVS price should be similar to the market to DSF price ratios of already included tests. One important issue often raised in key informant interviews was related to payments made to public sector facilities and public health care providers for delivering DSF services. The reimbursement to public sector facilities, unlike the reimbursement to private facilities, represents â&#x20AC;&#x153;incentive paymentsâ&#x20AC;? rather than reimbursing the cost of the services. Public sector health facilities and health care providers are already paid by the government and, therefore, the question was whether the public sector service providers or institutions should get paid for the services which they are supposed to provide anyway. Since the UHC is also the purchaser of services, it creates conflict of interest situation (restricting use of private sector facilities, over-reporting the services delivered).

Suggestion 9: To resolve the conflict of interest situation of public sector health care providers (UHC), two alternative approaches can be adopted; (i) Making UHC as the service provider only (payment of incentives can continue) without being in charge of purchasing or (ii) No incentive payments to public sector facilities and providers but UHC remains the purchaser of private services. If the incentive payments to public health care providers are continued, the programme should evaluate the possible implications of lowering the incentive payments.

Suggestion 10: The programme should develop a system of monitoring actual delivery of maternal health services by designated health care providers. Possibility of misreporting quantities of services provided is high because of associated incentive payments. The monitoring system should also monitor the quality of services delivered by both the public and private sector health care providers. The MHVS prices for different services are also creating incentive and disincentive effects on health care providers. The market price ratio of caesarean and normal delivery is about 4.0. The MHVS pays Tk. 400 for a normal delivery (including drug cost of Tk.100) and Tk. 6,000 for a caesarean section, implying a ratio of 15.0, much higher than the ratio of these two services in the market. Such a big shift in price ratios encourages health care providers to perform caesarean section delivery at a higher rate than necessary. If the money paid to the doctor in public sector health facility is considered, the ratio of these two modes of delivery becomes even more lop-sided. The physician making the decision gets Tk.60 for a normal delivery and Tk. 1,100 for a caesarean section delivery (ratio of 18.0).

Suggestions 11: Rationalize the difference in payments for C-section and normal deliveries in the programme. The prices for modes of deliveries may be set at a fixed level to reduce incentives for conducting C-section deliveries. If public sector incentives are continued, the programme should carefully evaluate the prices to use. A good starting point would be to pay about Tk. 600 per delivery, irrespective of mode of delivery. For private sector as well, the price per delivery should be similar. The equalization of C-section and normal delivery prices may create some unintended consequences. One possibility is that the UHC would have incentives to refer pregnant women at upper level facilities for conducting C-sections.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Suggestion 12: Community level health workers should receive trainings on early detection of potential beneficiaries. The payment for registration of a beneficiary should not be offered if the community health workers identify the beneficiary after the second trimester of pregnancy.

d. Targeting poor mothers None of the studies conducted on DSF-MHVS estimated the targeting efficiency. It is not known how effective the programme is in reaching the poor mothers. There are indirect indications that the targeting is not working well. In the field surveys, the team observed significant issues with identifying the poor. In fact, almost all beneficiaries interviewed during the field visits appeared to be from middle income group or better. Given the performance of other social protection programmes in Bangladesh, it is unlikely that the MHVS will have better targeting efficiency than other similar interventions. To improve the targeting efficiency, one approach could be to implement â&#x20AC;&#x153;geographic targetingâ&#x20AC;?, i.e., selecting relatively poor upazilas for the implementation of the programme. In Bangladesh, if poorest 50 upazilas are selected by the headcount ratio of poverty, the upazilas will be very different from the upazilas now in the programme. The list of upazilas with the highest poverty rates is shown in Annex D. Note that only eight of the current DSF upazilas are in this list. Once the upazilas are selected on the basis of poverty rate, the programme can consider implementing a universal voucher scheme without trying to identify who is poor and who is not. If the universal program is implemented in poor upazilas and using first or second pregnancies as eligible, targeting efficiency rate will be about 60% (60% of those who are in the program will be poor) with 100% of the poor covered by the programme. This level of targeting efficiency will be higher than the targeting efficiency of most of the social protection programmes in Bangladesh intending to reach the poor. In fact, if geographic targeting is used, more than 16% of poor pregnant women can be reached by implementing the programme in 50 poorest upazilas. Total cost of the program will increase as the number of pregnant women targeted will become about 170,000. If the programme intends to reduce the cost, it can consider enrolling only the first pregnancies in MHVS rather than enrolling the first and second pregnancies. Total expenses would be Tk. 550 million with Tk. 116.3 million as overhead expenses if the programme adopts universal targeting in poorest upazilas of Bangladesh. The overhead expenses in relative terms will decline to 21% from current level of 27%. Therefore, implementing the programme in poor areas will have significantly higher value for money compared to current situation. If only the first child is targeted, annual cost of the programme will be Tk. 342 million with 30% as administrative cost.

Suggestion 13: The MHVS should consider targeting poorest upazilas of the country. Universal coverage of first and second pregnancies in poor upazilas will improve targeting efficiency to about 60%. The cost of the programme will increase by about 57% but the cost will remain same as the current cost if only the first pregnancies are targeted. The DSF-MHVS has not changed the criteria used to identify the poor for a number of years. Household income of Tk. 3100 per month appears too low, given the poverty line of the country and price changes over the last few years. If we use upper poverty line and correcting the poverty line using CPI, the poverty line for 2016-17 should be about Tk. 6700 per month for a family of three. In practice, however, the programme does not use the poverty criteria strictly in identifying the beneficiaries.

Suggestion 14: If the programme wants to continue with targeting individuals based on poverty of the household, targeting criteria should be revised to incorporate easily observable but specific and sensitive indicators like construction material used for housing, ownership of TV, etc. Targeting criteria that include income, land ownership should be avoided.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Suggestion 15: The programme should evaluate the possible implications of defining eligibility criteria to include poorest 50% of pregnant women rather than targeting poorest 15 to 20% of the population. Since the MMR is the highest in Bangladesh for the middle wealth category, enrolling poorest 50% should help improve maternal health outcomes significantly. In a universal targeting, if the programme allows use of public sector health facilities only, richer groups may not be interested in participating in the programme, effectively making the programme targeted towards the poorer sections of the population. The formula used by the programme to calculate the target number of beneficiaries per upazila overestimates the target numbers, which probably encourage field level implementers to enrol non-eligible pregnant women.

Suggestion 16: If within upazila targeting is used, DSF-MHVS may continue estimating target number of beneficiaries for each of the upazilas for programmatic reasons but the programme should not share the target numbers with the upazilas. The target number per upazila is likely to be biased and may lead to mistargeting.

e. Knowledge and communication related issues in the programme From discussions with the policy planners at the centre and field level implementers, it is clear that communications within the programme among personnel at different levels were quite poor. A significant proportion of QMs thought that incentive money provided to mothers for adopting safe delivery has been discontinued although that was not the case. The QMs are the principal contacts between the programme and the beneficiaries and therefore, wrong information trickles down from the QMs to all potential beneficiaries. This will have negative consequence on the programme.

Suggestion 17: The programme should try to reduce the communication gap between programme management and field level implementers. A system of regular two-way communications will allow project managers to better understand the issues and concerns experienced at the field level as well as field level implementers to become fully aware of the policies and procedures being reformed or changed. Late identification of beneficiaries is related to two types of communication and knowledge failures. If the programme is well publicized at the community level, eligible pregnant women are more likely to contact FWA and HA to report their pregnancies. The second failure is related to the effectiveness of the FWAs and HAs in identifying new pregnancy cases. Field level communication between the FWAs, HAs and the potential beneficiaries needs strengthening. One way to do this will be to adopt social mobilization strategy for making the community members aware of the programme activities and benefits.

Suggestion 18: MHVS should adopt social mobilization strategies to improve knowledge of potential beneficiaries in the communities as well as to help improve effectiveness of community level health workers in identifying eligible beneficiaries.

f. Data needs for improving effectiveness and efficiency of DSF During the field visit, it was observed that the programme level data were collected by the WHO QMs and then transmitted to the coordinators of the programme. The information is also sent to programme and deputy directors of DSF-MHVS. Major concern is that the data collection has not been integrated with the regular Health Management Information System (HMIS). The UHC HMIS reports data on services delivered by UHC to DSF-MHVS mothers. The programme needs a system of collecting information on services received by DSF-MHVS beneficiaries at all levels, including services delivered at home of the beneficiaries. All pieces of information can be integrated with the HMIS in order to improve timely flow of information from the field level to the centre.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Suggestion 19: The programme should develop a comprehensive Management Information System (MIS) for DSF-MHVS, which can be integrated with UHC HMIS. Integration with HMIS will help reduce the time-lag between service delivery and flow of funds to the upazila level. It will also improve the effectiveness of HMIS and help strengthen management of the programme and evidence-based decision making. There are no data on targeting efficiency of DSF-MHVS, i.e., it is not known what percent of poor pregnant women are actually enrolled in the programme and what percent of beneficiaries are poor. Community level household survey can be used to estimate targeting efficiency. Interviews conducted at exit from heath facilities will not be able to provide information on targeting efficiency. The quantities of maternal health services delivered to DSF-MHVS beneficiaries are also not verified by external entities. Service utilization are reported by the DSF upazilas and since the UHCs are both purchasers and providers of services, possibility of over-reporting utilization (reporting higher quantities of services delivered) and upcoming (e.g., reporting a normal delivery as C-section delivery) exist. No study has examined the degree of over-reporting and upcoming, if any.

Suggestion 20: The programme should conduct surveys and/or patient chart reviews to estimate the degree of mistargeting as well as possible over-reporting or up-coding of service delivery.

Comparison with other similar social protection programmes

This study focused on one social protection programme, the DSF-MHVS. The GOB has implemented many social protection programmes by targeting different segments of the population but some of the programmes are likely to have considerable overlapping even though they are administratively independent, implying inefficient use of administrative and management resources. For example, Maternal Allowance (MA) Programme for the poor with annual budget of Tk. 1,584 million should have considerable overlapping with DSF-MHVS in terms of beneficiaries covered. Low-income Lactating Mother Allowance (LMA) programme targets low-income women in urban areas and so will not have overlapping with DSF-MHVS (which is implemented in rural areas) but it is important to consider the benefits of expanding the programme in rural areas to provide assistance to disadvantaged women from early stage of pregnancies to weaning period of the baby up to two years of age. The programme costs of MA and potential overlap of the programme with DSFMHVS should be evaluated to identify the potentials for improving VfM of both the programmes. Therefore, the GOB should conduct similar diagnostic studies on similar social protection programmes to identify potential economies of scope.

Suggestion 21: Conduct diagnostic studies on other social protection programmes that target pregnant women and lactating mothers.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

VII. Concluding Remarks This report presents the results of a diagnostic study of Demand Side Financing of Maternal Health Voucher Scheme. Diagnostic study is not a full evaluation of a programme but an attempt to â&#x20AC;&#x153;diagnoseâ&#x20AC;? its problems and concerns through qualitative and quantitative approaches. This study has adopted a mixed method of analysis by combining key informant interviews with quantitative analysis of administrative data. Qualitative research approach included interviews with policy makers, development partners, implementing agencies, health care providers and programme beneficiaries. A structured questionnaire was used to collect information from the WHO Quality Managers on specific problems and concerns they face at upazila level or below. Two sets of quantitative data were made available from the programme, one related to budget allocation/expenditure by year since 2011 and the other one on utilization of maternal health services by DSFMHVS beneficiaries by month for the years 2011 to 2016. Budget and expenditure data for 2015-16 fiscal year indicates that total budget of the programme was Taka 492.2 million but total expenditure was Taka 312.4 million. A number of reasons may explain the divergence between budget allocation for the year and the actual expenditure. For example, delayed payments to health care providers and beneficiaries may explain a part of this divergence. However, given that only 63.5% of budget allocation was actually spent, it possibly indicates significant divergence between planned activities and activities actually performed by the programme. The reform plan of DSF-MHVS should carefully look into the reasons for the difference between budgetary outlays and actual expenditure with a view to design a mechanism for improved and efficient utilisation of funds. The long delay in the flow of funds from the national level accounts to upazila MHVS accounts was identified as a systemic issue that affects efficiency and effectiveness of the programme. Although the problem has been cited by all studies on MHVS since 2009, no systematic attempts were made to address this concern. The MOHFW in collaboration with the Ministry of Finance should take initiatives for improving the timelines for release and flow of funds. It is also suggested that the programme considers creating an imprest fund to help smooth-out the delay in the approval of programme plans and release of funds. The administrative data on service utilization report the quantities of various services utilized by DSF-MHVS beneficiaries. Using the quantities of services utilized, expenditure on incentive payments and payments for health services can be derived. For 2015-16, the estimated expenditures on services and incentives was Taka 272.6 million. Programme expenditure data indicate that total payment on services and incentives in the year was Taka 275.3 million, similar to the estimated expenses based on service utilization information. Expenditure on services and incentives to total expenditure was 0.87 if the administrative data on budget and expenditures are used. This implies that the overhead cost of the programme was about 13% in 2015-16. If all personnel costs involved with administration, management and implementation of the programme are included (salary of government officials as well as WHO based personnel assigned to DSF), the ratio becomes 0.73 implying that the overhead cost becomes 27%. Therefore, the overhead cost of the programme is quite reasonable, assuming that the service delivery data actually represents the quantities of services delivered. A comparison of unit prices of various services set by DSF-MHVS and the market prices of the services in one rural upazila of Bangladesh (used for comparative purposes only) indicate that the market prices are significantly higher than the official unit prices. Despite these differences, the providers did not complain about the relatively low prices reimbursed by the programme. The gaps between prices set by the programme and the market prices in rural upazilas create the opportunity for charging extra user fees to beneficiaries by both the public and private sector health care providers.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Therefore, the programme needs to adopt regular monitoring of out-of-pocket expenses incurred by DSF enrolees when receiving maternal health services. Another concern is the wide variability of market price to DSF-MHVS price ratios for different service-types. The price for C-section shows the lowest ratio of market price to programme adopted unit price but the ratio for normal delivery was much higher implying that the programme creates significantly higher monetary incentives to conduct C-section deliveries. The payments to public sector health care providers are also biased in favour of C-section delivery. There are some indications that the programme enrolees experience much higher rates of C-section delivery compared to other women not in the programme. The payments for C-section and normal deliveries should be rationalised to discourage over-utilization of C-section deliveries. If not addressed, the concerns related to unnecessary C-sections conducted by health care providers may actually discourage utilization of health facilities by DSF-MHVS beneficiaries, which may have other negative consequences on maternal health outcomes. Therefore, this is an important issue needing immediate attention. It is proposed that the reimbursements for normal and C-section deliveries be made equal to lower the rate of unnecessary C-sections. The DSF-MHVS has identified specific maternal health services required for improving health outcomes of mothers and neonates. Since the services are listed explicitly by the programme, it is important to come up with a comprehensive list. For example, blood groupings and blood sugar tests are not listed as part of ANC. These tests as well as ultrasound for complicated pregnancies should be included in the list of services covered by the programme. This does not necessarily imply that the programme should set unit prices for each of these services. It is possible to define all-inclusive package price with penalty for not providing the required laboratory and diagnostic tests. It is proposed that the selection of upazilas for scaling up DSFâ&#x20AC;&#x201C;MHVS be based on small area poverty mapping and poorest upazilas should be selected for inclusion. Even though some of the current DSF-MHVS upazilas do not belong to poorest or second poorest quintiles of upazilas of the country, the programme may continue in these upazilas. If the programme selects 50 poorest upazilas of the country for scaling-up, even a universal targeting will improve targeting efficiency of reaching poor pregnant women to 60%. For the success of DSF-MHVS, it is extremely important to ensure timely payment to beneficiaries so that the payments would be viewed as incentive payments for services utilized rather than an income supplementation. Different modes of paying beneficiaries have been discussed in this report and it is suggested that the beneficiaries be offered a number of alternative options for receiving payments. The options offered may include deposit to bank accounts, e-cash, mobile banking, postal money order, etc. The choice of options will also encourage competition among the monetary service providers. The purpose, roles and involvement of public and private sectors at the upazila level should be clearly defined so that policy reforms can be guided by taking into account their specific roles and functions. In the current system, public provider at the upazila level acts as the service provider as well as purchaser of services. This creates conflict of interest situations. Potential consequences of conflict of interest environment should be identified and addressed in the reform plan. Since the possibility of misreporting service utilization is there, it is important to verify the reported deliveries happening at UHCs, private facilities, union level facilities and in community clinics. The degree of misreporting can possibly be reduced by lowering the gap between incentive payments to mothers for safe delivery at home and at health facility. Facility based delivery incentive payments may be reduced to Tk. 1000 while the home delivery incentive can be increased from the current level of Tk. 500.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Reported budget and expenditure indicate that the programme spent virtually no resources on publicity and advertisements since 2011. It is proposed that the programme adopt a comprehensive social mobilization strategy including distribution of â&#x20AC;&#x2DC;user-friendlyâ&#x20AC;&#x2122; informational booklet on pregnancy, safe pregnancy practices, pregnancy complications, nutrition, danger signs, care of newborn, importance of breast feeding, etc. Social mobilization is an integrating process where stakeholders are provided with information, tools and skills to become active participants. SOCMOB calls for the involvement of all relevant sectors of society for a common development objective (Hetzel, 2004). The overall reforms for DSF-MHVS should also take into consideration the macro-picture, and closely look at how coordination with similar programmes such as the Lactating Mothers Allowance and Maternity Allowance may help improve efficiency and effectiveness of the programmes. The draft report of the study was discussed in a meeting in the MOHFW on December 15, 2016. Major stakeholders of the scheme in the Government along with the representatives of concerned Development Partners participated in the meeting. There was a general consensus in the meeting on the findings and suggestions made in this report. The next step should be to prepare a realistic reform plan for implementation of the recommendations put forward in the report. The GOB and SPFMSP project should take necessary initiatives in this direction. The approved minutes of the meeting can be found in Annex G of the report.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

References Ahmed, S., & Khan, M. (2011). A maternal health voucher scheme: what have we learned from the demand-side financing scheme in Bangladesh? Health Policy and Planning, 25â&#x20AC;&#x201C;32. Anwar, I., Blaakman, A., & Akhter, S. (September 2013). Program Evaluation for Demand Side Financing Maternal Health Voucher Scheme in Bangladesh: Final Report. Dhaka. BBS, B. B. (September 2016). Statistical Yearbook Bangladesh 2015. Dhaka: Ministry of Planning, Government of Bangladesh. Farzana, S. (March 2014). Demand Side Financing (DSF) - Maternal Health Voucher Scheme in Bangladesh. Bangladesh: Government of Bangladesh and World Health Organization. Halim, M. A. (March 2014). An Analysis of Facility based Exit Interview with the Maternal Voucher Recipients under Demand Side Financing Initiative in Bangladesh. Dhaka. Hatt, L., Nguyen, H., Sloan, N., Miner, S., Magvanjav, O., Sharma, A., . . . Wang, H. (February 2010). Economic Evaluation of Demand-Side Financing (DSF) for Maternal Health in Bangladesh. Bethesda: Abt Associates Inc. Hetzel, B. (2004). Towards global elimination of brain damage due to iodine deficiency, Section IV by Jack Ling. Oxford University Press. HEU, H. E. (2012). Summary: Bangladesh National Health Accounts 1997-2012. Dhaka: Govt of Bangladesh. Hoque, M., Powell-Jackson, T., Dasgupta, S., Chowdury, M., & Koblinsky, M. (2012). Costs of Maternal Health-related Complications in Bangladesh. Journal of Health, Population and Nutrition, 30(2), 205-212. Koehlmoos, T., Ashraf, A., Kabir, H., Islam, Z., Gazi, R., Saha, N., & Khyang, J. (September 2008). Rapid Assessment of Demand-side Financing Experiences in Bangladesh. Dhaka: ICDDR,B. NIPORT, N. I. (December 2012). Bangladesh Maternal Mortality and Health Care Survey 2010. Bangladesh: Govt of Bangladesh, USAID, AusAID and UNFPA. NIPORT, N. I. (March 2016). Bangladesh Demographic and Health Survey 2014. Dhaka: NIPORT, USAID and Mitra Associates. Noor, F., & Rob, U. (2013). Does Maternal Health Voucher Scheme Have an Impact on Out-of-pocket Expenditure and Utilization of Delivery Care Services in Rural Bangladesh? Dhaka: Population Council. Noor, F., Talukder, N., & Rob, U. (2013). Effect of a maternal health voucher scheme on out-of-pocket expenditure and use of delivery care services in rural Bangladesh: A prospective controlled study. Lancet, (p. 20). Rahman, M., Rob, U., Noor, F., & Bellows, B. (2013). Out-of-pocket expenses for maternity care in rural Bangladesh: A public-private comparison. International Quarterly of Community Health Education, Volume 33(2), 143-157. Rannan-Eliya, R. G. (Technical Report B, 2012). Impact of maternal and child health private expenditure on poverty and inequity: Out-of-pocket payments by patients at Ministry of Health and Family Welfare facilities in Bangladesh, and the impact of the Maternal Voucher Scheme on costs and access of mot. Mandaluyong City. Sabur, M. A. (December 2015). Cash Transfer Modality for Demand Side Financing (DSF). Dhaka: Ministry of Health and Family Welfare, Government of Bangladesh. World Bank, W. (2013). Poverty Assessment: Assessing a Decade of Progress in Reducing Poverty, 2000-2010. Dhaka: Bangladesh Development Series Paper No. 31.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Annex A: DSF Upazilas with their 2010 Poverty Head-Count Ratio Table A1: Listing of DSF Upazilas ranked by percent of poor in the upazila and National Ranking of the DSF Upazilas using Poverty Rates in all Upazilas Poverty rank of DSF upazilas among all upazilas in Bangladesh Serial #

District

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

KURIGRAM JAMALPUR RANGPUR JAMALPUR BARISAL PIROJPUR MYMENSINGH SATKHIRA CHANDPUR SATKHIRA SHARIATPUR DINAJPUR SIRAJGANJ GAIBANDHA JAMALPUR JESSORE GOPALGANJ KHULNA SIRAJGANJ MADARIPUR COMILLA COX'S BAZAR COX'S BAZAR COMILLA COMILLA BAGERHAT COX'S BAZAR PANCHAGARH FARIDPUR THAKURGAON NARSINGDI MAULVIBAZAR

District

SUNAMGANJ

Upazila Upazila % extreme code poor 4994 ULIPUR 46.2 3915 DEWANGANJ 41.6 8527 GANGACHARA 39.0 3958 MADARGANJ 38.2 610 BANARI PARA 38.1 7976 NAZIRPUR 36.6 6124 HALUAGHAT 30.6 8786 SHYAMNAGAR 33.8 1379 MATLAB UTTAR 28.6 8704 ASSASUNI 32.0 8665 NARIA 30.5 2760 KHANSAMA 25.8 8827 CHAUHALI 28.1 3230 GOBINDAGANJ 29.0 3985 SARISHABARI 27.6 4111 CHAUGACHHA 20.7 3591 TUNGIPARA 26.1 4764 PAIKGACHHA 23.3 8867 SHAHJADPUR 25.1 5487 SHIB CHAR 20.2 1936 DAUDKANDI 21.0 2290 TEKNAF 19.7 2294 UKHIA 20.1 1994 TITAS 19.4 1975 MEGHNA 19.0 134 FAKIRHAT 19.2 2266 RAMU 17.8 7734 DEBIGANJ 16.6 2910 BHANGA 17.0 9451 HARIPUR 13.1 6864 ROYPURA 16.2 5883 SREEMANGAL 24.7 Poverty rank of DSF upazilas among all upazilas in Bangladesh Upazila code 9086

Upazila SULLA

% extreme poor 22.9

% poor 65.3 58.5 58.3 55.5 52.2 51.5 50.3 50.2 49.9 48.4 48.1 46.5 45.5 45.4 44.7 42.8 42.6 42.4 41.8 38.8 38.5 38.2 37.8 37.7 37.3 36.4 34.3 34.2 33.5 29.7 29.4 29.3

Rank

% poor 28.3

Rank

4 13 14 26 38 41 49 50 53 63 65 77 87 88 97 114 116 120 129 156 158 163 167 169 173 186 219 222 230 283 285 287

299

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

BHOLA HABIGANJ BRAHMANBARIA TANGAIL THAKURGAON JOYPURHAT KISHORGONJ NAWABGANJ TANGAIL MAULVIBAZAR NARAIL SUNAMGANJ PATUAKHALI MANIKGANJ LAKSHMIPUR MEHERPUR NAOGAON CHITTAGONG NOAKHALI KUSHTIA

925 3611 1204 9366 9408 3861 4892 7088 9385 5814 6528 9047 7866 5628 5158 5747 6403 1553 7510 5039

CHAR FASSON BANIACHONG BANCHHARAMPUR MIRZAPUR BALIADANGI KHETLAL TARAIL SHIBGANJ SAKHIPUR BARLEKHA KALIA JAGANNATHPUR KALA PARA HARIRAMPUR ROYPUR GANGNI Atrai MIRSHARAI CHATKHIL DAULATPUR

14.9 22.2 13.2 16.0 11.3 11.7 14.7 12.2 15.5 20.8 9.7 15.8 9.7 8.3 8.7 5.2 5.0 4.6 1.5 1.0

28.2 27.6 27.3 26.7 26.5 26.1 26.1 26.0 26.0 25.7 23.3 21.0 20.3 18.1 16.7 15.8 13.5 13.4 4.8 4.0

300 310 313 323 325 330 332 339 341 346 380 406 410 431 444 452 475 476 520 524

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Table A2: Calculating the target pregnancy cases by upazila using upazila level poverty rate Name of Upazila

Predicted 2016 population (1000) Male Femal e

Gross fert. rate (1000 women 15-49)

Estimat e of number of births

First or secon d births

ASSASUNI

138.2

141.4

4902

3088

Poor pregnan t women of total pregnan t 2372

1644

1208

73%

ATRAI BALIADANGI BANARI PARA BANCHHARAMPU R BANIACHONG BARLEKHA BHANGA CHAR FASSON CHATKHIL

98.1 105.0 71.1 139.5

101.8 103.9 75.0 169.4

58 76 74 88

3862 5162 3629 9750

2433 3252 2286 6143

521 1368 1894 2662

361 948 1313 1845

1953 1830 1539 643

540% 193% 117% 35%

178.8 127.7 129.2 236.9 87.9

192.0 142.4 144.6 243.4 108.0

78 61 72 91 99

9790 5681 6810 14486 6992

6168 3579 4290 9126 4405

2702 1460 2281 4085 336

1873 1012 1581 2831 233

513 778 1649 385 1846

27% 77% 104% 14% 794%

CHAUGACHHA CHAUHALI DAUDKANDI DAULATPUR DEBIGANJ DEWANGANJ

119.7 79.5 146.1 228.0 123.2 133.5

122.1 83.2 162.7 235.8 124.3 142.0

61 80 67 71 75 84

4871 4351 7128 10947 6094 7802

3069 2741 4491 6897 3839 4915

2085 1980 2744 438 2084 4564

1445 1372 1902 303 1444 3163

1826 484 2084 4664 2500 3651

126% 35% 110% 1537% 173% 115%

FAKIRHAT GANGACHARA GANGNI GOBINDAGANJ HALUAGHAT HARIPUR

69.0 157.5 153.3 268.8 146.1 78.4

69.6 161.0 162.1 277.3 154.5 80.8

60 110 69 63 93 76

2729 11584 7315 11422 9398 4018

1719 7298 4608 7196 5921 2531

993 6753 1156 5186 4727 1193

688 4680 801 3594 3276 827

700 2703 3579 6282 2704 1264

102% 58% 447% 175% 83% 153%

HARIRAMPUR JAGANNATHPUR KALA PARA KALIA KHANSAMA KHETLAL

58.2 137.6 130.5 111.1 92.5 51.7

68.6 142.0 127.8 115.2 91.7 52.6

71 65 56 98 64 49

3187 6034 4681 7384 3838 1684

2008 3802 2949 4652 2418 1061

577 1267 950 1721 1785 440

400 878 659 1192 1237 305

986 499 2968 577 2099 1182

247% 57% 451% 48% 170% 388%

MADARGANJ MATLAB UTTAR MEGHNA MIRSHARAI MIRZAPUR NARIA

135.9 144.1 60.5 189.0 200.2 109.5

143.7 160.9 59.9 224.7 231.1 126.2

84 78 67 60 78 74

7891 8206 2623 8817 11785 6107

4971 5170 1652 5555 7425 3847

4379 4095 978 1182 3147 2937

3035 2838 678 819 2181 2036

2386 2015 558 2174 2368 1425

79% 71% 82% 266% 109% 70%

Poor women with 1 or 2nd pregnanc y

Vouchers distribute d in 201516

Voucher s as % of eligible women

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) NAZIRPUR PAIKGACHHA RAMU ROYPUR Name of Upazila

92.5

4296

2707

2213

1533

1597

104%

122.0 125.5 153.8 152.4 139.0 157.4 Predicted 2016 population (1000) Male Femal e

89.5

57 81 64

4679 8073 6588 Estimat e of number of births

2948 5086 4150 First or secon d births

1375 1919 762

2174 2508 1135 Vouchers distribute d in 201516

158% 131% 149% Voucher s as % of eligible women

3825 1480 2932

2781 2910 1916

73% 197% 65%

ROYPURA SAKHIPUR SARISHABARI UPAZILA SHAHJADPUR SHIB CHAR SHIBGANJ SHYAMNAGAR SREEMANGAL SULLA TARAIL

273.7 137.3 159.0

308.7 161.0 172.3

93 78 84

18774 8214 9467

11828 5175 5964

1984 2769 1100 Poor pregnan t women of total pregnan t 5520 2136 4232

302.9 153.1 313.0 149.6 167.7 59.1 79.0

309.0 163.5 324.7 171.3 172.6 59.9 84.2

80 87 78 53 61 65 102

16165 9303 16561 5938 6883 2545 5614

10184 5861 10433 3741 4336 1603 3537

6757 3609 4306 2981 2017 720 1465

4683 2501 2984 2066 1398 499 1016

3236 1671 7232 3506 2082 334 1772

69% 67% 242% 170% 149% 67% 174%

TEKNAF TITAS TUNGIPARA UKHIA ULIPUR

149.7 94.0 50.5 119.5 197.3

153.0 105.8 51.6 120.7 217.2

81 67 76 81 53

8105 4637 2563 6393 7527

5106 2921 1615 4028 4742

3096 1748 1092 2417 4915

2146 1211 757 1675 3406

1700 321 1284 1248 3592

79% 26% 170% 75% 105%

Gross fert. rate (1000 women 15-49)

Poor women with 1 or 2nd pregnanc y

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Annex B: Questionnaire used to survey the Quality Managers of DSF Demand Side Financing: Maternal Voucher Scheme Opinion survey on the operational aspects of the program 1. The upazilas in which you are working now: (i) ______________, (ii) ____________ 2. List three most important problems faced by the DSF scheme in these two areas? (i)

__________________________________

(ii)

__________________________________

(iii)

__________________________________

3. Suggest what can be done to solve or lower the problems you have identified _______________________________________________________________________________________________ _______________________________________________________________________________________________ _________________________________________________________________ 4. How does the program identify poor pregnant women in the area? Describe. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _________________________________________________________________ 5. Who identifies the pregnant women for participation in the program? ____________________________ _______________________________________________________________________________________________ ___________________________________________________________________________ 6. Is there any independent verification whether the pregnant woman is poor or not? (Yes/No) _________ 7. What percent of poor pregnant women do you think are actually in the program? ___________________ 8. What percent of pregnant women in the program are actually poor? _____________________________ 9. Propose alternative ways of identifying poor pregnant women for participation in the program? _____________________________________________________________________________________ _______________________________________________________________________________________________ ___________________________________________________________________________ 10. Do you think all the health care providers get their money eventually for the services they provide to DSF women (even if delayed)? (Yes/No) ________________________ 11. If Q10 is no, what percent of providers ultimately get their money or incentives for the services they provide to DSF beneficiaries? ___________________ 12. What is the â&#x20AC;&#x153;averageâ&#x20AC;? time gap (in months) between service provision and actual receipt of money by health care providers? ___________________ 13. What percent of health care providers, in your opinion, get their money within three months of service provision to DSF mothers? _________________________ 14. Is the payment made to government sector health care providers take less time than payment to private sector providers (if private providers exist)? ______________ 15. What percent of health care providers, in your opinion, do not receive their payments within six months after the service provision? ___________________________________ 35

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) 16. Do you think all the beneficiaries ultimately get their transportation related money for the services they have sought for health care providers? ________________________ 17. What is the â&#x20AC;&#x153;averageâ&#x20AC;? time gap, in months, between receiving of the service and actual receipt of transport money by the beneficiaries? ___________________________ 18. What percent of beneficiaries, in your opinion, get their transport related expenses within three months of service utilization? _________________________ 19. Does the transportation expense payment made to relatively better-off beneficiaries take lower time than payment made to poor beneficiaries? ________________________ 20. What percent of women, in your opinion, do not receive their payments within six months after the service provision? _____________________________________ 21. Do women get their new-born incentive money on time? ______________________ 22. What is the average time gap between delivery of the baby and receipt of the new-born incentive package the mothers? _____________________________________ 23. Can you suggest ways to reduce the time gap between service provision and receipt of the money? _______________________________________________________________________________________________ ___________________________________________________________________________ 24. What are the possible consequences for the program not receiving the money on a timely basis? _______________________________________________________________________________________________ ___________________________________________________________________________ 25. Do the DSF women spend additional money for receiving maternal health services from government health care facilities (not including transport expenses or food expenses)? __________________________ 26. Do the DSF women spend additional money for receiving maternal health services from private health care facilities (not including transport expenses or food expenses)? _______________________________ 27. Do you think the DSF program is good for poor pregnant women? (Yes/No) ______________________ 28. Do you think the DSF program creates trust problems between health care providers and the beneficiaries? Why and how? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 29. Any other important issues you would like to mention? ______________________________________ _______________________________________________________________________________________________ ___________________________________________________________________________ 30. Any other comments and suggestions? __________________________________________________ _______________________________________________________________________________________________ ___________________________________________________________________________

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Annex C: Budget and Expenditures of DSF MHVS Name of the Programme: DSF SL #

Economic code

Year: July 2011-June 2013, In Lac Taka (100,000)

Heads

2011-2012 Allocation GoB Dev. RPA (through GoB)

1 2

4801 4815

Transport Expenses (for pregnant women) Postage

3 4 5 6 7 8

4827 4828 4833 4840 4842 4846

Printing and publications Stationaries, seals & stamps Publicity and advertisement Training (for service provider) Orientation Transportation cost

9 10 11 12 13 14

4854 4868 4869 4883 4886 4887

Procure usable goods Treatment and surgical goods supply Voucher fund (treatment) Honorarium (cash incentives for mothers) Survey Copy

15 16 17 18

4895 4899 6815 6821

Committee meetings Other expenditure Computer and spare parts Furniture Total CPI

2012-2013

Expenditure GoB Dev. RPA (through GoB)

Allocation GoB Dev. RPA (through GoB)

Expenditure GoB Dev. RPA (through GoB)

700.00 2.00

600.00 -

525.00 -

40.00 5.00 4.00

8.00 150.00 400.00 -

4.99 -

150.00 400.00 -

44.00 0.25 -

165.00 350.00 -

43.95 -

165.00 350.00 -

2.00 -

5.00 18.00 1,700.00 3,385.15 18.00 8.00

0.47 -

1,646.30 2,680.23

0.25 -

13.61 1,535.58 1,920.50

8.00

18.11 1,650.00 1,920.50 13.18

13.18

4.00 283.00 20.00 14.20 6,715.35 170.19

5.46

4.00 283.00 5,771.53

44.50

4.40 270.00 25.48 24.50 5,041.17 181.73

43.95

4.40 270.00 25.47 24.50 4,847.24

51.00

4801: Transport Expenses (to beneficiaries); Total 5 visits (3 ANC, one delivery and 1 PNC visit-100 taka for each visit) and taka 500 for referral. 4840: Training and Orientation of service provider: All doctors, nurses and other staffs of health and family planning department working at UHC, all field staff of both health and FP department (30 in each batch) 4842: Advocacy and Orientation: Upazila DSF committee members, Union DSF committee members (30 in each batch) 4869: Voucher Fund: All service providers Incentives and all medicines and all MSR.

Name of the Programme: DSF 37

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Year: July 2013-June 2015, In Lac Taka (100,000) SL #

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Economic code

4801 4815 4827 4828 4833 4840 4842 4846 4854 4868 4869 4883 4886 4887 4895 4899 6815 6821

Heads

2013-2014 Allocation GoB Dev. RPA (through GoB)

Transport Expenses (for pregnant women) Postage Printing and publications Stationaries, seals & stamps Publicity and advertisement Training (for service provider) Orientation Transportation cost Procure usable goods Treatment and surgical goods supply Voucher fund (treatment) Honorarium (cash incentives for mothers) Survey Copy Committee meetings Other expenditure Computer and spare parts Furniture Total CPI

2014-2015

Expenditure GoB RPA (through Dev. GoB)

GoB Dev.

Allocation RPA (through GoB)

49.81 0.40 -

700.00 181.50 484.00 2,050.00 2,500.00

35.07 0.26 -

464.67 139.43 248.59 1,731.29 2,497.01

50.00 -

600.00 228.00 361.90 2,200.00 2,400.00

14.52 4.84 600.00 6,715.35 195.08

50.21

14.37 0.28 6,534.86

2.50 35.33

17.91 5.86 2.00 5,095.64 207.58

51.00

Expenditure GoB RPA Dev. (through GoB) 107.67 34.95 130.97 231.83 1,802.13 582.67 52.50

0.97 5,815.67

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Name of the Programme: DSF Year: July 2015-June 2016, In Lac Taka (100,000) SL #

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Economic code

4801 4815 4827 4828 4833 4840 4842 4846 4854 4868 4869 4883 4886 4887 4895 4899 6815 6821

Heads

2015-2016 Allocation GoB Dev. RPA (through GoB)

Expenditure GoB RPA (through Dev. GoB)

55.00 -

498.22 130.00 235.00 2,000.00 2,000.00

40.79 -

279.02 115.70 213.93 1,287.72 1,186.48

51.00

2.00 2.00 6,715.35 220.88

55.00

0.46 4,867.22

Average per year 2011-16 in 2015-16 prices Allocation Expenditure GoB RPA (through GoB RPA Dev. GoB) Dev. (through GoB) 713.40 467.31 0.52 54.00 35.52 1.36 0.09 2.08 0.06 194.67 161.63 422.53 337.32 1.04 0.58 1.30 0.12 9.07 3.31 2,174.78 1,833.73 2,822.42 2,089.30 4.67 12.38 8.53 4.85 2.47 274.96 139.09 12.21 6.19 0.53 9.64 5.96 40.79 3,083.31 57.60 6,659.48

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Expenses per upazila under DSF based on historical budget and expense numbers (in Lac Taka, 2015-16 prices) SL #

Economic code

Heads

Average budget per upazila 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

4801 4815 4827 4828 4833 4840 4842 4846 4854 4868 4869 4883 4886 4887 4895 4899 6815 6821

Average Expenditure per upazila

13.46 0.01 1.02 0.03 0.04 3.67 7.97 0.02 0.04 0.17 41.03 53.25 0.09 0.23 0.09 5.19 0.23 0.19 126.74

8.82 0.00 0.67 0.00 0.00 3.05 6.36 0.00 0.00 0.06 34.60 39.42 0.00 0.16 0.05 2.62 0.12 0.11 96.05

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Annex D: List of Poorest 50 upazilas of Bangladesh zlcode

zila-name

upz-code

upazila-name

% Extreme Poor (lower poverty line)

% Poor (Upper poverty line)

Rank

KURIGRAM

4908

CHAR RAJIBPUR

48.7

68.8

KURIGRAM

4918

PHULBARI

48.8

68.5

KURIGRAM

4977

RAJARHAT

48.6

67.7

KURIGRAM

4994

ULIPUR

46.2

65.3

KURIGRAM

4906

BHURUNGAMARI

44.7

65.1

KURIGRAM

4961

NAGESHWARI

45.4

BARISAL

662

MHENDIGANJ

64.4

BARISAL

636

HIZLA

49.5

62.3

CHANDPUR

1347

HAIM CHAR

61.3

KURIGRAM

4909

CHILMARI

42.1

61.1

MYMENSINGH

6172

NANDAIL

41.8

60.7

MYMENSINGH

6181

PHULPUR

39.2

58.8

JAMALPUR

3915

DEWANGANJ

41.6

58.5

Yes

RANGPUR

8527

GANGACHARA

58.3

Yes

SHARIATPUR

8636

GOSAIRHAT

40.7

58.3

MYMENSINGH

6116

DHOBAURA

38.4

58.2

BARISAL

669

MULADI

44.1

58.2

GAIBANDHA

3221

FULCHHARI

39.8

58.1

KURIGRAM

4952

KURIGRAM SADAR

40.5

KURIGRAM

4979

RAUMARI

SHARIATPUR

8614

BHEDARGANJ

38.3

56.3

CHANDPUR

1358

KACHUA

56.3

MYMENSINGH

6131

ISHWARGANJ

35.8

SHERPUR

8988

SHERPUR SADAR

35.6

55.8

BARISAL

632

GAURNADI

39.9

55.5

JAMALPUR

3958

MADARGANJ

38.2

55.5

BARISAL

607

BAKERGANJ

42.2

55.4

DSF Upazila?

Yes

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) 39

JAMALPUR

3929

ISLAMPUR

38.2

SHARIATPUR

8694

ZANJIRA

34.9

CHANDPUR

1349

HAJIGANJ

32.5

53.7

CHANDPUR

1376

MATLAB DAKSHIN

32.4

53.7

BANDARBAN

395

THANCHI

31.7

GAIBANDHA

3288

SAGHATA

34.1

52.8

MYMENSINGH

6120

FULBARIA

32.8

52.6

SYLHET

9141

GOWAINGHAT

46.5

52.6

RANGPUR

8592

TARAGANJ

32.4

52.4

MYMENSINGH

6152

MYMENSINGH SADAR

39.3

52.3

BARISAL

610

BANARI PARA

38.1

52.2

PIROJPUR

7947

KAWKHALI

39.6

52.2

BARISAL

694

WAZIRPUR

37.8

52.1

PIROJPUR

7976

NAZIRPUR

36.6

51.5

BARISAL

602

AGAILJHARA

38.2

51.1

GAIBANDHA

3282

SADULLAPUR

31.1

MAGURA

5566

MOHAMMADPUR

30.6

50.8

MYMENSINGH

6123

GAURIPUR

30.5

50.6

RAJBARI

8229

GOALANDA

31.8

50.5

CHANDPUR

1395

SHAHRASTI

29.5

50.5

JAMALPUR

3907

BAKSHIGANJ

34.3

50.4

MYMENSINGH

6124

HALUAGHAT

30.6

50.3

Yes

SATKHIRA

8786

SHYAMNAGAR

33.8

50.2

Yes

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Annex E: List of Individuals met during the field visits and in Dhaka, Bangladesh Persons/Organisations Consulted and discussed on DSF Programme: Government of Bangladesh in Dhaka         

Mr. Md. Moslem Chowdhury-Additional Secretary, Ministry of finance and NPD, SPFMSP Project Mr. Monzurul Alam Bhuiyan-Joint Secretary, MOF and ED, SPFMSP Project Mr. Ataur Rahman-Deputy Secretary, DD, SPFMSP Project Mr. M M Reza-Advisor, P.M.M.U, Ministry of Health and Family Welfare. Dr. Mohiuddin Osmani-Joint Chief Planning, MOH & FW Mr. Ibrahim Khalil-Senior Assistant Chief. Dr. Saidur Rahman-Director, PHC and LD, MNCAH, DGHS Dr. Pabitra Kumar Sikder-Deputy Director and Programme Manager Dr. A K M Rafiqul Hyder-DPM, DSF

World Health Organization      

Dr. Edwin C. Salvador, Medical Officer, Public Health Administration Dr. Murad Sultan, NPO, Health System Dr. Md. Mohsin, Consultant DSF, WHO Dr. Deen Mohammad, National Coordinator, WHO DSF Cell Two Zonal Coordinators 26 Upazilla Quality Managers

Maxwell Stamps LLC, Dhaka, Bangladesh       

Mr. Duncan King, Project Director, SPFMSP project Mr. Dan Wartonick, Ex Team Leader, SPFMSP Project Mr. Siddiqur Rahman Choudhury, Acting Team Leader, SPFMSP Project Dr. Kavim V Bhatnagar-Social Protection Economist, SPFMSP Project Mr. Mozammel Haque-Social Protection Specialist, SPFMSP Project Ms. Treena Watson-Coordinator, SPFMSP Project Ms. Emily Wylde-over Video Conference

DFID, Dhaka  

Dr. Sahlina Ahmed, Health and Population Advisor, DFID Ms. Farhana Mostafa, Programme Manager, DFID

World Bank, Dhaka    

Dr. Bushra Bente Alam, Health Advisor, Dr. Shakil Ahmed, Senior Health Economist Dr. Asib Nasim, Consultant (Health) Dr. Tahmina Begum, Consultant Economist

UNFPA 

Dr. Syed Abu Jafar Md Musa, Advisor, UNFPA

Field visit meetings Daudkandi Upazilla, Comilla  

Mr. Md. Al-Amin, UNO, Daudkandi Dr. Shah Alam Molla, UH&FPO, Daudkandi

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS)      

Dr. Habibur Rahman, RMO, UHC, Daudkandi Upazila Family Planning Officer and five doctors of UHC Mr. Imran Hossain, WHO, Quality Manager Mr. Kamal Uddin, Owner and Chief Executive Officer, Kamal Hospital, Gouripur Mr. Abul Hashem Sarkar, Chairman, Gouripur Union Parishad And other members of the union parishad

Jamalpur District Hospital and Sharishabari Upazila, Jamalpur Jamalpur District Hospital        

Dr. Md. Abdullah Al-Amin, Superintendent and Assistant Director, Jamalpur District Hospital Dr. Md. Moshayer-ul-Islam, Civil Surgeon, Jamalpur Prof. M A Wakil, Principal, Jamalpur Medical College Dr. Tarun Kumar Dhar, Senior Consultant, Obs. & Gynae Dr. Md. Nurul Islam Talukdar, Senior Consultant, Anesthesia Dr. Md. Sirajul Islam, RMO of the General Hospital, Jamalpur Dr. Md. Ferdous Hasan, RMO, Jamalpur General Hospital Dr. Fakhria Alam, Junior Consultant, OBGYN, Jamalpur General Hospital

Sharishabari Upazila        

Dr. Md. Fazlul Haque, UHFPO Dr. Mumtaz Uddin Ahmed, RMO Dr. Brishti Ghosh, Medical Officer (MO) Dr. Mazreha Naeem Mishi, MO Dr. Md. Shahedur Rahman, MO Dr. M. Samia Islam, Dental Surgeon Mr. Bulbul Hossain; QM,WHO Mr. Shahabuddin, Health Inspector (in charge)

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Annex F: Comparative Summary Statements for DSF-MHVS Specific areas/ dimensions

Flow of funds and issues related to fund release and disbursement

Existing provision

Issues and challenges

Proposed revisions

Rationale

Funds of the programme flow through multiple channels within Health and Finance Ministries.

Delays in flow of funds range from 3 to 12 months. The average delay in disbursing service providers and beneficiaries is about six to eight months, creating significant obstacles in smooth functioning of DSFâ&#x20AC;&#x201C;MHVS. First tranche of quarterly fund is usually released only during the second quarter creating a huge backlog of payment to service providers as well as to beneficiaries.

Budget allocative processes should be optimised; time lag between the adoption of budget and release of funds to MOHFW and then to the upazila level needs to be reduced to less than 30 days.

The time lags in the release of funds from Ministry of Finance to Ministry of Health can be reduced; adoption of improved information system can reduce time lag of flow of funds from MOHFW to upazila level MHVS account.

Establish an imprest account so that beneficiaries can be paid immediately after receiving the services.

Paying the beneficiaries through bank accounts is not working properly. Opening the bank account has not been easy for some beneficiaries. Getting the money through the bank accounts also involves additional expenses for beneficiaries. Issues and challenges

Beneficiaries be offered a number of options for reimbursing the incentive money or travel expenses. The options may include (a) bank account, (b) mobile banking, (c) ecash payment, (d) postal money order, etc.

The imprest account can smooth out the irregular flow of money. The imprest account money is considered an advance to be adjusted with expenditures after the submission of incentive and service related payment vouchers. Offering alternative options for receiving incentive funds will improve satisfaction of beneficiaries with the programme. It will also reduce cost of getting the incentive money from the perspective of beneficiaries. This will reduce the possibility of fund leakage. Rationale

Price and incentive schedule used by the programme may encourage providers to charge user fees to beneficiaries and to

a) Ratios of upazila level market prices to prices set by programme should be similar across services. The ratios now vary widely.

No provision for stop gap fund and / or contingency fund to meet day-to-day requirements of the programme.

Unit prices to health care providers and the incentive payments to beneficiaries are paid through bank accounts.

Specific areas/ dimensions Price and incentive schedule used by the programme for paying

Existing provision Unit prices are set by the programme to pay for different maternal health services.

Proposed revisions

The ratios of market to programme prices affect incentive structure of health care providers. Incentive payments to beneficiaries for home and

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) providers for various maternal health services

Specific areas/ dimensions Administrative and management related issues

overuse certain type of maternal health services

b) The gap in incentive payments to beneficiaries for institutional and home deliveries should be reduced.

For public sector health facilities, physicians deciding between normal and C-section delivery receive Tk. 60 per normal delivery but Tk. 1,100 for C-section delivery. Private sector facilities get Tk. 300 for normal delivery and Tk. 6,000 for Csection delivery.

The difference in payments between C-section and normal deliveries is very high encouraging delivery of babies through unnecessary Csections. C-section rate is significantly higher for DSF beneficiaries than non-DSF mothers.

The payments for C-section and normal deliveries should be reexamined to ensure that unnecessary C-sections are discouraged. The payment for Csection delivery and normal delivery may be equalized.

Not all necessary maternal health services are listed in the list of benefits of the programme. The programme benefits include tests for blood hemoglobin and urine test for albumin. No other laboratory and diagnostic tests are listed.

Health care providers often recommend tests for blood groupings and blood sugar. For some mothers, ultrasound is also recommended. Since these tests are not mentioned in the programme benefit package, DSF enrollees are often asked to pay for these services out of pocket.

Blood groupings, blood sugar test and ultrasound for complicated pregnancies can be listed under the benefit package.

Inclusion of these tests in the benefit package will lower the outof-pocket expenses of DSF-MHVS beneficiaries.

Existing provision

Issues and challenges

Proposed revisions

Rationale

Six MHVS implementation committees, three at national level, one at district level, one at upazila level and one at union level.

Not all committees are active and many did not meet in a year. Union level committees often not functional.

Different DSF committees may be streamlined for improved efficiency and the need for multiple committees in running DSF-MHVS may be reviewed.

Streamlining the DSF committees will improve efficiency of the programme. Reduction in the number of committees should reduce expenditures on orientation meetings, travel costs, etc.

institutional deliveries should be rationalized to discourage misreporting of institutional deliveries. Equal or quite similar level of payments for both normal and Csection deliveries will lower the likelihood of performing Csections that are not medically indicated.

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Specific areas/ dimensions

Identification of the beneficiaries of the programme

There is no personnel at the upazila level who is in charge of the DSF-MHVS. The WHO Quality Managers (QMs) were appointed on an adhoc basis.

Presence of WHO QMs appears essential for proper functioning of DSF-MHVS activities at upazila level and below. With the departure of the temporary QMs, the programme will have difficulty in implementing its activities.

One full-time staff should be appointed per upazila. This administrative person will be in charge of all programme activities including verification of eligibility, keeping contacts with stakeholders and beneficiaries, coordinating data collection using UHC Health Information System. Two alternative approaches can be adopted; (i) Making UHC the service provider (payment of incentives can continue) without being in charge of purchasing or (ii) No incentive payments to public sector facilities and providers but UHC remains the purchaser of services from private providers.

The programme needs a coordinator at the upazila level who will liaison with all the stakeholders at upazila, union and community levels. A full time staff is also needed to ensure that the DSF related information is collected and reported through the regular HMIS of UHC. To resolve the potential conflict of interest situation, health care delivery function should be separated from purchasing function of health facilities.

Upazila Health and Family Planning Officer (UHFPO) is in charge of DSF accounts at the upazila level. Upazila Health Complex is also a provider of DSF services in addition to paying for services provided by private health care facilities.

Since the UHC is also the purchaser of services, it creates conflict of interest situation (restricting use of private sector facilities, over-reporting the services delivered).

Currently, there is no independent verification of quantities and types of services provided.

Quantities of services delivered are possibly over-reported as the UHC is both payer and provider

Monitor quantity and quality of maternal health services delivered by public and private providers.

Possibility of misreporting quantities of services provided is high because of associated incentive payments.

Existing provision

Issues and challenges

Proposed revisions

Rationale

Criteria for selection of voucher holder are (a) monthly income of 3100 or less, (b) Land owned less then 0.15 acre, (c) does not have any other income source or productive assets.

The criteria used for identifying the potential beneficiaries are out-of-date. The specific criteria are not easy to observe or verify leading to selection of noneligible women.

Needs to be revisited considering the present socio economic condition. Easily observable housing and asset ownership characteristics should be used to identify the poor households.

Target numbers of women are estimated for each upazila using

Upazilas vary widely in terms of poverty rate as well as CBR.

Target number of eligible women should be calculated for the

Use of easily observable and verifiable characteristics will simplify identification of target population. Targeting efficiency can be improved if asset based or housing based characteristics are used. Budget needed for the programme depends on the

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Specific areas/ dimensions

Advocacy, communication and social mobilization

crude birth rate (CBR) of Bangladesh and assuming 40% of pregnancies as eligible.

Arbitrary use of 40% as eligible biases the target calculations.

programme using more realistic assumptions on poverty rate and CBR. Upazila specific estimates of target should be avoided.

The programme is now in operation in 53 upazilas of the country. The upazilas were not selected on the basis of poverty rate.

The programme should scale up its activities using upazila level poverty level. In the poor upazilas, the programme may adopt universal coverage rather than targeting poor households only.

Officially the DSF-MHVS uses poverty criteria to identify the poor pregnant women for enrollment in the programme.

Since the upazilas were not selected based on poverty rate, a significant number of upazilas in the programme do not show high rates of poverty. This increases the possibility of mistargeting. The official criteria are rarely used in practice and many of the enrolled women appear not poor.

The enrollment criteria may be revised to allow enrollment of poorest 50% women.

Maternal Mortality Ratio (MMR) is not the highest for poorest quintile. The MMR are high for all three poorest quintile and the middle wealth quintile showed the highest mean MMR. Therefore, not targeting narrowly the poorest quintile may not be a major concern.

Existing provision

Issues and challenges

Proposed revisions

Rationale

Little or no formal communications between central level policy makers and the upazila level programme managers and implementers

Lack of communication between the centre and field level often creates confusions in the implementation of the programme. In some cases, programme implementers are not fully aware of the policies and procedures. Programme management and field level service providers/ implementers lack knowledge

Organize regular contacts between programme management and field level implementers. Regular communications will allow managers to better understand issues/concerns at the field level and field level become aware of policy changes. Social mobilization activities should be organized on a regular basis to improve knowledge of all

Regular two-way communications will reduce the knowledge gap among various levels of the programme.

Little or no social mobilization and awareness initiatives

estimate of target number of eligible women. Using appropriate parameters in the estimation process is important to find the budget requirements. In poor upazilas, if all pregnant women are targeted, percent of poor pregnant women in the programme will be about 60%. Geographic targeting will have high targeting efficiency.

Lack of knowledge about the programme makes it difficult for health workers to recruit eligible

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Data needs and future research needs

implemented by the programme

about the programme and programme benefits

There is no data on targeting efficiency of the programme

Information on targeting efficiency is not known.

Reliability and validity of reported service utilization information is not known

Providers are paid on the basis of service utilization. Incentives exist to over-report utilization. Up-coding of services may also happen. The information system is adhoc and upazila HMIS does not collect all relevant information on DSF-MHVS.

Management information system of the programme is not comprehensive. The information is collected by Quality Managers (QMs) at the upazila level and then transmitted to the project.

stakeholders including the community members about DSFMHVS and it benefits Programme should conduct household surveys to estimate targeting efficiency, if universal targeting is not used Patient chart reviews to estimate the degree of mistargeting as well as possible over-reporting or upcoding of service delivery. DSF-MHVS should develop an integrated and comprehensive MIS and the system should be compatible with HMIS so that all information can eventually be integrated with regular HMIS.

women. Better understanding of programme benefits will improve service utilization. Without more information on targeting efficiency, it is difficult to design policies for better targeting. Services delivered may be misreported in some cases. To reduce mis-reporting, regular monitoring of service utilization is needed. Regular MIS will allow flow of information on a regular basis lowering the time-gap between service utilization and incentive payments. It should also strengthen regular HMIS.

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

Annex G: Minutes of the meeting on report presentation and discussion Government of the People's Republic of Bangladesh Ministry of Health and Family Welfare Planning Wing, Health-6 Bangladesh Secretariat, Dhaka MoHFW/AC(H-6) /DSF/2016/

Date: 04.01.2017

Subject: Minutes of the Meeting held on "Dissemination and Finalizing the Draft Report on Diagnostic of Demand Side Financing— Maternal Health Voucher Scheme.

A meeting was held on 14 December 2016 on "Dissemination and Finalizing the Draft Report on Diagnostic of Demand Side Financing— Maternal Health Voucher Scheme "in the Conference Room of Planning wing of the ministry of Health and welfare (MOHFW). Dr. A E Md. Muhiuddin Osmani, Joint Chief (Planning), MoHFW presided over the meeting. The list of the participants is appended as Annex-A. 2. Discussion: 2.1.

The Chairperson welcomed all to the meeting. After a brief introduction of all, the Chair then invited to make a Presentation on the DSF -MH VS programme for the MOHFW.

2.2.

The team of consultants headed by Prof. Mahmud Khan made the key presentation. He mentioned that the presentation is based on the draft report of the diagnostic study on DSFMHVS and findings of the study The suggestions and comments of the participants of this meeting would be addressed in the final report. He also informed that the study was mostly based on literature review.

2.3.

The presentation was followed by discussions including questions, suggestions, comments and feedback to be incorporated into the report. Main suggestions, comments and questions that were discussed are as follows: a) Distinction between the Market Price of Services by Private Sector and that of DSF Voucher should be clearly stated comparing the two at the rural / appropriate level b) Selection of Upazila for implementing / rolling out of DSF — MHVS should be based on Poverty Mapping and 50 most Poor Upazillas should be considered on priority basis. It was also discussed that the scheme could be universalised in those Upazilas. Argument put forward was based on an improvement in targeting efficiency level of the scheme that could be improved up to 60%. c) The inordinate delay in the fund flow from The MOHFW to Upazila of the programme was extensively discussed and was identified as a systemic issue. It was discussed that (SPFMSP) project of the Finance Division has a mandate to improve upon the PFM

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) structures of social protection schemes and should take the initiative of improving the efficiency and timelines for release and flow of funds of the DSF-MHVS programme. d) It was suggested that the Programme should also consider creating an imprest fund to contribute towards timely payments before the first quarter advance is released The SPFMSP suggested that this could be looked up further in the design of the reform plan. e) The issue of beneficiaries being paid by cheque was also discussed and it was suggested that the proposed reforms should also look Into easier methods to provide payment to beneficiaries. f)

The role and involvement of the private sector in service delivery should be clearly stated and concerns, if any, should be identified in the reform plan,

g) The proposed reform plan should also look into the reasons behind the difference between the budgetary outlays and the actual expenditure incurred in the programme with a view to design an improved and efficient utilisation of funds. h) The issue of differential rates for normal delivery and C-section was discussed and it was suggested by the consultants that the same should be rationalised and equated for an improved incentive structure. i)

It was suggested that 'user-friendly' guidelines in the form of a booklet should be developed by the MOHFW as part of the awareness campaign towards enhanced utilisation of health services amongst the potential beneficiaries.

The overall reforms for DSF-MHVS should also take into consideration the macro-picture, and closely look at how coordination with similar programmes such as the Lactating Mothers Allowance and Maternity Allowance may be improved.

k) A comparative statement showing the existing system along with the proposed system and reasons thereof should be provided as an annexure to the report. 3. Recommendations: 3.1.

The meeting unanimously adopted the following recommendations of the report discussed in the meeting.

Institutional arrangements and procedure for fund flow needs to be revisited to reduce the existing long time lag in payment to the beneficiaries as well as to the service providers. Possibility for establishing an imprest fund might be explored to reduce the delays in pavment, il. Reforming the existing payment system to the beneficiaries to include multiple payment options such as mobile banking, micro financial services, mobile payments etc might be considered; iii. For implementation of the programme, the poorest 50 upazilas should be selected first The possibility of universalization of the scheme in those 50 upazilas and the cost associated with It Should also be explored, iv. The rates provided for different services by the scheme should be reviewed/ rationalized to reduce the gap between the market price and also to avoid any distortion such as preference for unnecessary C â&#x20AC;&#x201D; section and diagnostic tests. v, Establish a mechanism for coordination amongst DSFâ&#x20AC;&#x201D;MHVS and similar programmes such as the Lactating Mothers Allowance and Maternity 51

Report on the Diagnostic Study of Demand Side Financing â&#x20AC;&#x201C; Maternal Voucher Scheme of Bangladesh (DSF-MHVS) Allowance. vi. A more 'user-friendly' guideline in the form of a booklet to be developed by the MOHFW as part of the awareness campaign towards enhanced utilisation of health services amongst the potential beneficiaries, 4. As there was no other issue to discuss the meeting was concluded with a vote of thanks from the Chair.

(Dr. A. E. Md. Muhiuddin Osmani) Joint Chief Ministry of Health and Family Welfare